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.