Job Requirements and Responsibilities: 

• The daily management of the hospital quality and patient safety team, including risk, infection control, patient advocacy and performance improvement.


• Coordinates the regulatory compliance program to meet the standards identified by the JACHO, DPH and CMS, including the National Patient Safety Goals.


• Support project structure to insure all staff is involved in regulatory readiness on a daily basis, including tracer rounds with defined tools and processes that include feedback from the patient and/or family, rounds with Senior Leadership and other unit/service specific tracers.


• Is knowledgeable of all standards specific to The Joint Commission, CMS, DPH, OSHA, FDA, etc.


• Is knowledgeable and versed in the completion of the annual Periodic Performance Review including identification of hospital vulnerabilities that require changes to ensure ongoing survey readiness.


• Works on a team to recommend and facilitate sustainability efforts to improve quality and patient safety, based on identified risks and hospital data. Regularly reviews the sustainability educational program for relevance, participation and effectiveness, and adjusts as needed.


• Develops and recommends the budgets for the areas managed. Manages activities to assure financial goals are met.

• Master’s degree in public health, nursing, health care administration, business administration or related area.


• 5 years related experience is required.


• RN degree preferred.


• Lean certification preferred.


• In depth experience with risk management principles, patient safety science, publicly report quality measures, operations analysis and quality management-performance improvement methods required.


• Ability to effectively utilize a variety of computerized software applications such as spreadsheet, word processing, relational database and graphics software packages required.


• Excellent communication skills accompanied by the ability to analyze and present data to influence behavior, stimulate innovation, promote best practices and drive organizational change.


• Highly skilled change agent with demonstrable sensitivity to the interpersonal, group dynamic, organization, political and perceptual issues associated with change.