Director, Quality & Safety
About The Position
The Director of Quality & Safety leads and oversees Anna Jaques Hospital’s comprehensive quality, patient safety, regulatory, risk management, infection prevention, and patient experience programs. Reporting to the Chief Medical Officer and partnering closely with the Chief Nursing Officer, Hospital President, medical staff leadership, and operational leaders, this role advances the hospital’s strategic quality agenda through leadership, education, data-driven performance improvement, and project management. The Director oversees hospital-wide performance improvement, patient safety initiatives, infection prevention and control, regulatory readiness, accreditation compliance, risk reduction, and patient experience improvement. The role serves as an internal consultant and subject matter expert, implementing and monitoring programs to support safe care across clinical and operational processes and fostering a culture of continuous improvement, accountability, transparency, high reliability, and patient-centered care. In partnership with executive leadership, the Director develops, operationalizes, and monitors outcome measures related to quality, safety, regulatory performance, and patient experience. The role analyzes, prioritizes, implements, evaluates, and communicates improvement initiatives aligned with Anna Jaques Hospital’s strategic goals and commitment to clinical excellence. The position also has accountability for departmental budget planning, resource management, and program effectiveness.
Requirements
- Bachelor’s degree in Nursing, Healthcare Administration, Public Health, or a related healthcare field.
- Massachusetts Registered Nurse license.
- Minimum of 8–10 years of progressive leadership experience in healthcare quality, patient safety, regulatory compliance, accreditation, or performance improvement.
- Demonstrated experience leading hospital-wide quality, patient safety, and patient experience initiatives.
- Experience with The Joint Commission, CMS, state regulatory requirements, and accreditation processes.
- Strong understanding of healthcare quality metrics, performance improvement methodologies, and patient experience strategies.
- Exceptional leadership and relationship-building skills.
- Strong analytical skills and ability to interpret, present, and use data to drive organizational improvement.
- Outstanding communication and presentation skills, including the ability to influence stakeholders at all levels.
- Ability to lead organizational change and foster a culture of safety, quality, and service excellence.
- Demonstrated success managing complex projects and multidisciplinary teams.
- Commitment to patient-centered care and continuous improvement.
- Demonstrated commitment and actions to valuing diversity and contributing to an inclusive working and learning environment.
- Must be vaccinated against influenza as a condition of employment.
Nice To Haves
- Master’s degree in a healthcare-related discipline.
Responsibilities
- Lead and oversee hospital-wide quality improvement, patient safety, and performance excellence initiatives.
- Develop and support systems for tracking, evaluating, reporting, and improving quality and patient safety outcomes.
- Collaborate with physicians, nursing leadership, and operational leaders to reduce preventable harm and improve clinical outcomes.
- Provide consultation, education, and coaching on quality improvement methodologies, patient safety principles, and evidence-based practices.
- Promote Lean, PDSA cycles, Root Cause Analysis (RCA), Failure Mode and Effects Analysis (FMEA), and other improvement methodologies.
- Analyze quality and patient safety trends and recommend action plans to improve outcomes and reduce variation in care delivery.
- Support medical staff peer review, occurrence reporting, event investigations, and corrective action planning.
- Lead development and implementation of a patient experience strategy aligned with the hospital’s mission and values.
- Monitor and analyze HCAHPS, Press Ganey, and other patient feedback measures to identify improvement opportunities.
- Partner with clinical and operational leaders to improve patient engagement, communication, responsiveness, and patient satisfaction.
- Promote patient- and family-centered care and develop service excellence initiatives across the continuum of care.
- Facilitate patient experience improvement projects and ensure accountability for organizational goals and benchmarks.
- Lead organizational readiness for compliance with The Joint Commission, CMS, Massachusetts Department of Public Health, and other regulatory agencies.
- Promote continuous survey readiness and regulatory compliance, and partner with leaders to support understanding and sustained compliance.
- Coordinate regulatory surveys, audits, corrective action plans, and follow-up activities.
- Oversee the Infection Prevention and Control Program and collaborate with clinical leadership to reduce healthcare-associated infections.
- Support risk management activities and initiatives to reduce organizational risk and improve safety culture.
- Oversee quality, safety, patient experience, and performance reporting programs, including data collection, validation, analysis, benchmarking, and public reporting.
- Present performance data, trends, and recommendations to executive leadership, medical staff committees, governing boards, and frontline teams.
- Monitor metrics related to clinical quality outcomes, patient safety indicators, infection prevention, patient experience, CMS quality programs, Leapfrog initiatives, commercial payer quality incentives, and organizational strategic goals.
- Facilitate multidisciplinary committees, forums, and workgroups focused on quality, safety, regulatory compliance, and patient experience.
- Build collaborative relationships with physicians, nursing leaders, department directors, and external agencies.
- Promote innovation, accountability, transparency, and continuous improvement as a change agent.
- Develop educational programs and learning opportunities to advance quality, safety, and patient experience competencies.
- Participate in strategic planning and organizational initiatives supporting operational and clinical excellence.
- Manage departmental budget planning, resources, and program effectiveness.
- Promote the organization’s WE CARE values and contribute to an inclusive working and learning environment.
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What This Job Offers
Job Type
Full-time
Career Level
Director
