Responsible for overseeing the development, implementation, and continuous improvement of patient safety and quality programs within the organization. Ensures compliance with accreditation standards, regulatory requirements, and industry best practices to deliver high-quality, safe care to patients. Collaborate with clinical and administrative teams to drive initiatives that reduce risk, enhance patient outcomes, and foster a culture of safety.

Education

• Bachelors Level Degree (Required)

Experience

• 5 years of Leadership

• 5 years of Healthcare Operations

• Performance Improvement

Responsibilities

• Provide strategic oversight and support for the hospital’s Patient Safety Program, providing expert guidance to top management on improving the safety culture.

• Lead root cause analysis, tools, and behavioral training initiatives, while evaluating program effectiveness and analyzing data.

• Collaborate with the System-Wide Patient Safety Director to ensure alignment with corporate initiatives.

• Facilitate organization-wide quality improvement activities, ensuring continuous readiness and compliance with healthcare accreditation standards, CMS Core Measures, PFP, MU quality data, and Q-HIP programs.

• Oversee the coordination of quality and performance improvement (PI) initiatives, including the management of reporting and tracking systems to maintain ongoing quality and performance monitoring.  

• Oversee OPPE and peer review activities to ensure the achievement and maintenance of high-quality care standards.  

• Coordinate annual evaluations and hospital DNV/ISO surveys, including required follow-up actions and internal audit compliance. ​