Sr Director of Quality/Patient Safety

Nashville General Hospital is hiring a Full Time Sr Director of Quality/Patient Safety for Quality Assurance in Nashville, Tennessee.   

Shift: Day Shift 

Primary Duties and Responsibilities

Patient Safety & High-Reliability Operations
• Oversee hospital-wide patient safety programs, including:
 Event reporting systems
 Root Cause Analyses (RCA)
 Failure Mode and Effects Analysis (FMEA)
 Serious safety event management
 Promote Just Culture principles and psychological safety for staff.
 Lead efforts to reduce hospital-acquired conditions (HACs), preventable readmissions, and adverse 
events.
 Ensure timely follow-up, corrective action planning, and sustainability of safety improvements
Quality & Regulatory Readiness: 
• Implement, maintain, and evaluate a comprehensive Quality and Patient Safety program that oversees care delivery 
performance and outcomes.
• Serve as the primary point of contact for The Joint Commission, CMS, CDC, and Leapfrog; coordinate all 
accreditation standards, surveys, and reporting in collaboration with leaders. 
• Lead clinical risk management investigations, incident report analysis, and serve as a lead investigator for Root 
Cause Analysis (RCA) and Failure Mode and Effects Analysis (FMEA).
• Oversee the integration of infection prevention and contamination control principles across all hospital units.

Clinical Excellence & Professional Development: 
• Direct an integrated program for clinical excellence, incorporating Lean Six Sigma, Change Management, and 
Project Management methodologies into staff development.
• Oversee the peer review program and Ongoing Professional Practice Evaluation (OPPE) support in conjunction with 
physician leadership to ensure medical staff competency and high-quality care.
• QI support with GME programs, leading and responsible for Patient Resident Safety
• Transfer and implement High Reliability Organization (HRO) principles, behaviors, and tools across the 
organization to foster a culture of safety and excellence.
• Link clinical outcomes and patient satisfaction data to targeted professional development initiatives to address 
identified performance gaps.

Data Analysis and Reporting
• Oversee the collection, validation, analysis, and interpretation of quality and patient safety data.
• Identify trends, disparities, and opportunities for improvement.
• Present quality and safety performance reports to executive leadership, medical staff committees, and the Board of Trustees

Experience 
This senior executive position requires a minimum of 10 years of progressive healthcare leadership experience. This must include at least 3 to 5 years in a senior leadership role (e.g., Senior Director or Director) within an acute care hospital with ambulatory settings, with a preference for experience in an Essential Hospital or a similar complex healthcare setting. The ideal candidate will have a proven track record in the design, development, and implementation of Quality, Incident Management, and Patient Safety programs. They must demonstrate success in improving clinical quality and patient experience outcomes by utilizing Lean Six Sigma and High Reliability Organization (HRO) principles. Experience in a teaching hospital or academic medical center, particularly in collaborating with Medical Staff Services and physician leadership for peer review and OPPE support, is highly preferred

Required Skills & Qualifications:  

• Bachelor level of Nursing; 
• Active RN Licensure required.
• Master’s degree in Nursing (MSN), Healthcare Administration (MHA), Business Administration (MBA), Quality and Safety (MHA) or a related field
• Two of the following certifications (or equivalent) CPHQ, CPSO, CQMS, CLSSB at the time hire or obtained within 12 months of hired date (Candidates with a nursing or other clinical license will be given special consideration)
•  A minimum of (3) years of experience in the role of Director, Senior Director, or comparable, at an acute care hospital, preferably at an “Essential Hospital” or hospital operating in a similar capacity.
• A minimum of (3) years of direct experience in the design, development and implementation of Quality/Incident Management/Lean/Patient Safety/Patient Experience/HRO.
• Knowledgeable of Joint Commission, CMS, CDC, and Leapfrog standards and demonstrated proficiency navigating the assessment and survey processes to achieve desirable and sustainable outcomes.
• Strong practitioner of LSS, Quality Management System, assessment