Director, Clinical Quality and Patient Safety

Director, Clinical Quality and Patient Safety

The Director, Clinical Quality and Patient Safety provides strategic executive oversight and clinical guidance to a defined Service Area, encompassing multiple acute care facilities. This high-impact role is the accountable leader for the overall development, implementation, and rigorous enforcement of all Clinical Quality Management, Patient Safety, Infection Prevention, and Risk Mitigation programs. This role requires a highly experienced leader dedicated to achieving High Reliability Organization (HRO) status and maintaining continuous regulatory compliance.

Strategic Accountabilities & Essential Functions

I. Regulatory Compliance & Accreditation

Regulatory Leadership : Serve as the chief expert and liaison for all regulatory bodies, ensuring continuous readiness and full compliance with Joint Commission (TJC), CMS, and CDPH standards across the service area.

Quality Program Management : Direct the development and implementation of all clinical quality and patient safety programs, utilizing Daily Management Systems and data to monitor, analyze, and improve performance.

Medical Staff Partnership : Partner with and direct medical staff leadership to manage peer review, practitioner performance review, and professional oversight processes.

II. Patient Safety & Risk Mitigation

High Reliability Organization (HRO) : Lead and champion the service area's journey toward High Reliability, driving cultural and process changes to minimize risk and medical errors.

Risk Mitigation : Define and oversee risk management efforts, utilizing Root Cause Analysis (RCA) and other assessment tools to establish effective corrective action plans for all significant events and near misses.

Infection Control : Oversee the Infection Prevention and Control Programs, serving as the primary contact during outbreak management and ensuring compliance related to architectural design and operations.

III. Performance Improvement & Data Analytics

Performance Improvement (PI) : Utilize advanced PI methodologies (e.g., Lean, Six Sigma) to identify systematic barriers and drive the standardization of evidence-based guidelines across clinical departments.

Data Strategy : Oversee the systems for data management, interpreting complex health data analytics and trends to advise executive leadership on long-term strategy and population health needs.

Minimum Qualifications & Mandatory Requirements

Education and Experience

Education : Master's degree in Business, Health Care, Public Administration, or a directly related field is Required.

Experience : Minimum ten (10) years of experience in clinical or quality settings, with extensive experience in Clinical Quality management.

Leadership Experience : Minimum nine (9) years of experience in a leadership role.

Mandatory Certifications (Non-Negotiable)

RN (Registered Nurse) license is Required (reflecting the clinical background).

CPHQ (Certified Professional in Healthcare Quality) or other equivalent Quality Certification is Required.

HRO Training (High Reliability Organization Training) is Required.

Must obtain a Professional Healthcare Quality Certificate within 24 months of hire.

Required Skills and Expertise

Regulatory : Expertise in managing compliance with Joint Commission (TJC), CMS, and CDPH.

Operational : Experience leading teams, High Reliability Experience, and proficiency with Daily Management Systems.

Leadership : Demonstrated ability to lead teams, drive organizational change, and provide expert consultation to executive stakeholders.

Preferred Skills

Formal Performance Improvement (PI) training or certifications (e.g., Lean, Six Sigma).

Strong experience in Business Process Improvement and Health Care Data Analytics.