Director, Patient Safety and Quality (RN)

At NorthBay Health, the Director is responsible for overall hospital group patient safety and quality improvement initiatives in alignment with the organizational strategic plan and goals as well as the Medical Staff office function. Facilitates the transition from a retrospective, reactive model for patient safety to a prospective, proactive harm reducing patient safety program promoting the tenets of a High Reliability Organization. Provides direction toward safety practices and process improvements that support the mitigation of health care errors and the factors attributed to them that contribute to unintended adverse patient outcomes and conducts Root Cause Analysis as needed. Coordinates quality improvement across the care continuum and patient safety activities, including clinical process transformation, guideline implementation and improvement of clinical outcomes through data collection and analysis. The Director plans, directs, organizes, and improves functions associated with operations to meet all pertinent regulatory and accreditation requirements, organizational readiness and compliance to ensure that NorthBay standards, policies, procedures and practices are consistent with state and federal regulations as well as JC requirements. Oversight of the Infection Prevention team and the reduction of hospital acquired infections. Responsible for the oversight of physician peer review. Including the continuation of peer review process redesign. 

Oversight of the medico-legal aspects of the medical staff service, and compliance with accreditation and regulatory requirements (i.e., JC, Accreditation Association for Ambulatory HealthCare Inc. (AAAHC), National Committee on Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), Institute for Medical Quality (IMQ), and the California Department of Public Health (CDPH) in regards to medical staff functions. Responsible for Medical Staff Services, including physician and allied health practitioner credentialing and re-credentialing, focused professional practice evaluation management, meeting management, flow of information from medical staff committees through the Medical Executive Committee, Medical Practices Credentialing Peer Review Committee, Medical Advisory Committee, Operating Committee and/or the Governing Board as appropriate. Maintains a working knowledge of the medical staff bylaws, rules and regulations, and policies and keeps the medical staff updated on all changes. Responsible for establishing, contributing to, and maintaining continuity in the development, and implementation of standards and regulations applicable to the medical staff, related to credentialing, quality, and administrative functions. Provides consultative expertise to the medical staff and administration on options and actions to meet those standards. Develops and maintains the Continuing Medical Education program to include compliance with accreditation requirements.  Responsible for budgetary management. 

At NorthBay Health, our vision is to be the trusted healthcare partner of choice for the communities we serve. We are dedicated to improving the well-being of our community by providing accessible, high-quality care to all who need it. Every member of our team plays a vital role in delivering compassionate and effective healthcare solutions. We invite you to join us in our mission to ensure that every patient and family member feels valued, respected, and cared for throughout their healthcare journey.

Education: Baccalaureate Degree in nursing. Master’s degree in nursing or related healthcare field preferred. 

Licensure/Certification:  California RN licensure required. Certified Professional in Health Care Quality (CPHQ) preferred. 

Experience: Five years of direct combined experience in acute care and ambulatory care settings.  Five years of demonstrated progressive management experience with increasing scope of responsibility with the last two years at a Director level preferred. Previous experience in leading Patient Safety with a focus on High Reliability and Zero Harm.  Previous experience working with Medical Staff Leadership.  Strong knowledge of accreditation and regulatory requirements (The Joint Commission, National Committee on Quality Assurance, California Department of Public Health, Centers for Medicare and Medicaid, AAAHC, IMQ, CMS). Must possess a thorough understanding of the quality payment programs and quality pay for performance initiatives.   

Skills: Knowledge of statistical tools and analysis. Demonstrated initiative, follow through and ability to work independently. Demonstrated results-oriented leadership style. Demonstrated effective project management skills. Excellent interpersonal, judgment and problem-solving skills Excellent written and verbal communication and presentati