DIRECTOR OF QUALITY IMPROVEMENT AND PATIENT SAFETY

Samaritan Health Services•Portland, OR

1d•$49 - $65•Onsite

About The Position

The Director of Quality Improvement and Patient Safety provides strategic leadership, operational direction, and administrative oversight of Samaritan Medical Center’s Quality Improvement and Patient Safety Department. Reporting to the Vice President for Medical Affairs and Chief Medical Officer (VPMA/CMO), the Director advances patient care, clinical excellence, patient experience, and the goal of zero preventable harm in alignment with the organization’s mission and priorities. The role leads hospital-wide quality improvement, patient safety science, high reliability practices, regulatory readiness, clinical analytics, and mandatory reporting. It works with medical, nursing, and operational leaders to set quality priorities, implement clinical interventions, and monitor performance against national benchmarks, including CMS ratings and value programs and the Leapfrog Hospital Safety Grade. The Director supervises and develops department staff, manages daily operations and budgets, and coordinates work across Quality, Patient Safety, Infection Prevention, Risk Management, and Case Management. The position chairs the Quality Council and the Joint Commission and Regulatory Steering Committee, supports other clinical governance committees, and presents quality and safety analyses to the Board of Trustees Quality Committee on behalf of the CMO. It serves as the administrative liaison to regulatory and accreditation bodies and leads continuous survey readiness, regulatory investigations, and corrective action plans. The role also participates in the administrative on-call rotation and may be called back for regulatory surveys, audits, clinical crises, or serious safety events. This is an exempt, salaried executive management position with 80 position hours. Work is conducted in a professional office and acute hospital environment, with frequent rounds in patient care units, surgical suites, and outpatient departments. There is no routine direct patient contact, though the position has broad institutional impact on patient safety and clinical outcomes. The role requires access to protected health information and confidential peer review and regulatory materials.

Requirements

Graduate of an accredited professional nursing program and current, active New York State Registered Professional Nurse (RN) licensure.
Bachelor’s degree in Nursing (BSN) or a related healthcare discipline.
At least five years of progressive clinical healthcare experience in an acute care hospital environment.
At least three years of clinical supervisory, managerial, or program leadership experience in quality improvement, patient safety, clinical risk, nursing leadership, or regulatory compliance.
Working knowledge of The Joint Commission standards, NYS DOH Title 10 regulations, CMS Conditions of Participation, and public reporting systems.
Practical understanding of RCA2, FMEA, and Just Culture algorithms.
Competency in clinical data analysis, statistical process control, electronic health record workflows, and Microsoft Excel, Word, and PowerPoint.
Strong interpersonal, diplomatic, and communication skills, including the ability to engage physicians, medical staff leaders, nursing leadership, board members, and regulatory auditors.
Ability to build multidisciplinary consensus, manage complex projects under tight deadlines, and exercise objective judgment in stressful clinical review situations.
High standards of integrity, ethical conduct, objectivity, and confidentiality regarding protected health information and peer review proceedings.
Willingness and ability to obtain CPHQ or CPPS certification within 24 to 36 months of appointment if not credentialed upon hire.
Ability to participate in administrative on-call rotation and respond to emergency call-backs.
Ability to sit, walk, stand, and move throughout a multi-floor facility; occasionally lift or transport items up to 10 pounds.

Nice To Haves

Master’s degree in Nursing (MSN), Healthcare Administration (MHA), Business Administration (MBA), Public Health (MPH), or Healthcare Quality; candidates currently enrolled in an accredited graduate program with an established completion plan will be considered.
Certified Professional in Healthcare Quality (CPHQ) or Certified Professional in Patient Safety (CPPS).
Formal training in Lean, Six Sigma, or Institute for Healthcare Improvement (IHI) methodologies.

Responsibilities

Lead organization-wide clinical quality and patient safety initiatives to reduce preventable harm and hospital mortality and improve clinical outcomes.
Partner with the CMO and executive management to set annual quality metrics and clinical targets aligned with organizational goals.
Deploy evidence-based improvement methods, including PDSA, Lean, Six Sigma, and IHI best-practice bundles, across acute, ambulatory, and procedural services.
Lead patient safety investigations and risk assessments, including RCA2, FMEA, clinical risk assessments, and apparent cause evaluations.
Promote High Reliability Organization principles and Just Culture; oversee safety briefings, leadership safety rounds, and non-punitive incident and near-miss reporting.
Track and direct performance strategies for national and state quality ratings, benchmarks, incentive programs, and clinical registries, including CMS ratings, VBP, HACRP, Leapfrog, ACS NSQIP, and specialty registries.
Analyze statistical process control data, identify trends and variation, assess interventions, and report findings to executive and quality governance bodies.
Oversee and manage the Quality Improvement and Patient Safety Department, including direct supervision and evaluation of its staff.
Coordinate workflows and communications among Quality, Patient Safety, Infection Prevention, Risk Management, and Case Management.
Develop and manage departmental operating and capital budgets, resources, staffing models, and performance goals.
Participate in the administrative on-call rotation and lead immediate administrative response and preliminary review of sentinel events or clinical crises.
Oversee quality data supporting Medical Staff governance, including OPPE and FPPE indicators, and support the Medical Staff Peer Review Committee.
Chair the Quality Council and Joint Commission and Regulatory Steering Committee; support the Patient Safety Committee, Performance Improvement Council, and Medical Management Committee.
Represent Quality on designated clinical and medical staff committees and present quality and safety analyses to the Board of Trustees Quality Committee on behalf of the CMO.
Serve as administrative liaison to The Joint Commission, NYS DOH, OPMC, CMS, OMH, and other regulatory or accreditation entities.
Maintain continuous survey readiness through tracers, environmental rounds, policy reviews, and mock surveys; direct corrective action plans and regulatory investigations and correspondence.
Serve as point of contact for QIOs, managed care entities, and external payers on quality-of-care complaints and clinical validation inquiries.
Direct validation, extraction, and submission of state and federal quality measures, including CMS eCQMs, IQR, OQR, and clinical registry requirements.
Maintain quality data governance and integrity and translate data into dashboards, run charts, and scorecards.
Serve as the NYS DOH Health Commerce System Coordinator, overseeing account provisioning, communications, directory accuracy, and HERDS disaster surveillance reporting.