Director of Quality – Women’s and Children Services

University Hospitals•Cleveland, OH

About The Position

The Director of Quality, Safety, Accreditation and Policy provides strategic and operational leadership for clinical quality, patient safety, regulatory readiness, accreditation compliance, and organizational policy management across a large, complex medical center. The Director establishes priorities and aligns clinical and operational functions, partnering with physician, nursing, operational, and administrative executives to advance high reliability, continuous improvement, regulatory excellence, and patient-centered care. The role is accountable for designing, executing, and sustaining quality improvement, patient safety, accreditation, policy governance, performance measurement, and regulatory compliance programs. It translates organizational strategy into medical center-wide priorities, evaluates performance and risk, directs corrective action, and advises executive leaders on achieving organizational goals and external standards. The Director oversees quality and performance improvement, patient safety, accreditation and regulatory compliance, policy management, academic mission support, and departmental operations. Responsibilities include setting improvement priorities and performance expectations; maintaining reliable quality reporting; directing safety event review and corrective action; overseeing regulatory readiness and responses to deficiencies; ensuring effective policy governance; supporting quality and safety education; managing departmental goals, budgets, staffing, and resources; and advising and presenting to executive and governing bodies. The role also represents the medical center with external regulators, accrediting organizations, professional associations, and community partners as assigned. The position requires a bachelor’s degree in a related field and at least eight years of relevant healthcare quality, patient safety, accreditation, regulatory, and clinical leadership experience, including several years in people management. A master’s degree and listed professional certifications are preferred. Physical demands include frequent sitting, talking, repetitive motions, and eye/hand/foot coordination, with occasional standing, walking, handling, and grasping; lifting and carrying up to 20 pounds are rare. Travel is listed as 10%25.

Requirements

Bachelor’s degree in Healthcare Administration, Nursing, Public Health, Business Administration, or a related field.
At least 8 years of experience in healthcare quality, patient safety, accreditation, regulatory, and clinical leadership, including several years in a people management capacity.
Experience within an academic medical center, integrated delivery system, or large healthcare organization.
Ability to lead multidisciplinary teams, influence senior and executive leaders, manage organizational change, and sustain measurable results across complex operations.
Ability to manage budgets, staffing plans, and resource allocation for a complex function or department.
Ability to comply with requirements for safely and securely maintaining protected health information.

Nice To Haves

Master’s degree in Healthcare Administration, Nursing, Public Health, Business Administration, or a related field.
Experience with Joint Commission or DNV survey leadership.
Experience overseeing policy governance.
Experience presenting to governing boards, executive committees, medical staff leadership, or comparable senior governance groups.
Certified Professional in Healthcare Quality (CPHQ).
Certified Professional in Patient Safety (CPPS).
Lean Six Sigma Green Belt, Black Belt, or equivalent.
Healthcare accreditation or regulatory certification.

Responsibilities

Establish and lead quality, safety, accreditation, and policy strategy aligned with organizational strategy and medical center priorities.
Set the performance improvement agenda and direct organization-wide and departmental initiatives, including prioritization, resource allocation, accountability, and sustainability.
Set performance expectations and governance for quality indicators, publicly reported measures, regulatory metrics, and improvement commitments; intervene when performance or compliance is at risk.
Lead data-driven improvement efforts using Lean, Six Sigma, PDSA, and other methodologies.
Oversee the integrity, interpretation, and executive communication of quality dashboards, scorecards, and performance reports, including recommendations and escalation.
Partner with physician and nursing leaders to improve clinical outcomes, reliability, equity, and patient experience.
Exercise decision-making authority within the assigned portfolio and escalate material quality, safety, regulatory, or accreditation risks.
Establish accountability structures for performance improvement plans and verify corrective actions produce sustained results.
Lead the patient safety program and promote a culture of safety, high reliability, transparency, learning, and accountability.
Direct governance for event reporting, root cause analyses, apparent cause analyses, and corrective action plans; ensure timely escalation, leadership accountability, and validation of sustained risk reduction.
Monitor serious safety events, near misses, and high-reliability metrics in partnership with Risk and clinical loss control.
Collaborate with risk management, infection prevention, and operational leaders on safety priorities.
Integrate patient safety, infection prevention, clinical risk, quality improvement, and regulatory priorities across care settings.
Support evidence-based practices to reduce preventable harm.
Oversee readiness for Joint Commission, DNV, CMS, state, and specialty accreditation, partnering with the designated accreditation leader on priorities, corrective actions, and escalation of unresolved risks.
Oversee responses to survey findings and regulatory deficiencies, including corrective action governance, evidence submission, validation of sustained compliance, and executive escalation.
Monitor regulatory changes, communicate implications to leadership, and partner with operational leaders to address gaps and sustain compliance.
Lead policy governance and document control processes, including development, approval, publication, review, exception management, and retirement standards.
Ensure policies are current, evidence-based, and aligned with regulatory requirements.
Coordinate policy review cycles and approvals with clinical, operational, legal, compliance, and executive stakeholders.
Evaluate policy compliance trends, identify improvement opportunities, and resolve or escalate cross-functional policy conflicts and implementation gaps.
Maintain oversight of organizational policy standards and publication processes in collaboration with relevant leaders.
Collaborate with medical school, residency, fellowship, and research leadership to integrate quality, safety, and regulatory expectations into organizational programs.
Support quality and safety education for medical students, residents, fellows, and faculty.
Establish departmental goals, operating plans, budgets, staffing models, and resource priorities; monitor financial and operational performance and adjust plans as needed.
Build leadership capability and succession plans for relevant professionals and hold direct reports accountable for measurable outcomes.
Advise executive, physician, nursing, and operational leaders on performance, risk, regulatory exposure, and improvement priorities.
Present performance to governing boards, executive committees, and medical staff leadership; recommend decisions, investments, and corrective actions.
Chair or lead multidisciplinary governance committees and establish agendas, assign accountability, and escalate unresolved issues.
Negotiate priorities and resource needs while protecting regulatory compliance, patient safety, and organizational performance.
Represent the medical center in organization-wide councils and, as assigned, with external regulators, accrediting organizations, professional associations, and community partners.
Perform other duties as assigned, comply with policies and standards, and comply with requirements for safeguarding protected health information.