Director of Quality & Patient Safety

Job Summary:

Reporting to the Chief Medical Officer, the Director of Quality and Patient Safety leads the development and implementation of a comprehensive quality and patient safety program that drives clinical excellence, innovation, and evidence-based practice. They ensure compliance with CMS, The Joint Commission and specialty certification program standards. The Director provides strategic leadership for quality improvement, patient safety, accreditation and certification activities. This role also assists in creating, tracking, and reporting on health equity initiatives, with a focus on minimizing disparities.

The Director collaborates closely with infection prevention, risk management, department chairs and section chiefs, the nursing department, administration, and interdisciplinary teams to identify improvement opportunities and establish reliable, consistent approaches with clearly defined objectives and metrics.

Duties and Responsibilities:

Quality and Performance Leadership

• Lead all quality management functions, including patient care quality, patient safety, regulatory compliance, and performance improvement.
• Develop and execute strategic quality plans, policies, and organization-wide improvement initiatives.
• Foster a culture of continuous improvement and data-driven decision-making.

Regulatory Compliance and Accreditation

• Oversee preparation for accreditation and certification surveys (e.g., The Joint Commission, CMS) to ensure full compliance with all regulatory and quality standards.
• Ensure ongoing adherence to state and federal requirements, including patient safety standards and documentation guidelines.
• Prepare and submit timely, accurate reports to regulatory agencies and accreditation bodies.

Data, Metrics and Reporting

• Establish and monitor quality metrics, dashboards, and data analysis systems to identify improvement opportunities.
• Ensure accurate and timely data collection and access relevant hospital databases for reporting.
• Prepare and present analyses and quality performance reports to hospital leadership and regulatory bodies.

Clinical Quality and Outcomes Improvement

• Collaborate with clinical and administrative teams to implement evidence-based practices and improve care delivery across the hospital.
• Continuously monitor clinical outcomes, enhance value, and minimize patient harm.
• Apply current clinical practice guidelines, professional standards, and regulatory requirements when evaluating patient care.
• Act as a change agent to develop and optimize processes, workflows, and training for clinical and medical staff.
• Advocate and model a Just Culture framework that encourages open reporting of incidents and near-misses without fear of retribution.

Health Equity and Value-Based Care

• Support development, tracking, and reporting of health equity initiatives.
• Integrate health equity metrics into executive dashboards to align with value-based care objectives.

Operations, Finance and Staff Leadership

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