DIRECTOR OF QUALITY IMPROVEMENT AND PATIENT SAFETY - Full-time

Location:

Samaritan Medical Center

Department:

01.8742 SMC HEALTHCARE RESOURCE

Pay Range:

$49.10 - $81.02

Care for our community, and your career.

The Director of Quality Improvement and Patient Safety is a key executive leader responsible for setting the vision and direction of all quality initiatives at Samaritan Medical Center. This role directly impacts the hospital’s clinical reputation, operational performance, and financial sustainability.

The Director serves as the chief architect of the hospital’s quality strategy, shifting the focus from reactive quality assurance (QA) to proactive quality improvement (QI). As a collaborative change agent, the Director partners with clinical and operational leaders to drive continuous improvement, enhance patient safety, and ensure regulatory compliance. By reducing inefficiencies and eliminating waste, the Director transforms the quality department into a value-generating entity. This position reports to the Chief Medical Officer (CMO).

Responsibilities
The Director of Quality Improvement oversees a broad portfolio of responsibilities, with three primary functions: Strategic Planning and Leadership, Data Management and Analysis, and Regulatory Compliance and Accreditation Oversight.

Strategic Planning and Leadership

• Lead the development and implementation of a comprehensive quality improvement plan aligned with the hospital’s strategic goals.
• Provide expert guidance to senior leadership, translating data and trends into a clear quality roadmap.
• Collaboratively lead performance initiatives with clinical and operational leaders to achieve defined quality goals.
• Ensure quality initiatives are embedded across all hospital operations.

Data Management and Analysis

• Oversee the collection, analysis, and interpretation of clinical and operational data to identify trends and track performance.
• At the request of the CMO, prepare and present detailed quality reports for the Board of Directors, committees, and senior leadership.
• Lead data-driven investigations using Root Cause Analyses (RCAs) and proactive assessments using Failure Mode and Effect Analyses (FMEAs).
• Apply improvement methods such as Lean Six Sigma to reduce variation and eliminate waste.

Regulatory Compliance and Accreditation Oversight

• Serve as the primary authority on regulatory and accreditation matters.
• Ensure continuous compliance with all state and federal regulations.
• Manage and report required quality measures to external entities.
• Lead all survey preparations, including Joint Commission (TJC) readiness, mock surveys, and tracer methodology reviews.
• Oversee quality reporting for CMS requirements, including measures that inform Star Ratings and value-based purchasing.

Fostering a Culture of Quality and Safety

• Promote a culture of continuous improvement and patient safety.
• Implement and support a “Just Culture” approach, encouraging open reporting of events and near-misses without fear of retribution.
• Develop and deliver QI training programs for staff at all levels.
• Partner with physicians, nurses, and other professionals to build system-wide accountability.

Team and Fiscal Management

• Lead and mentor a team of quality professionals, supporting their performance and development.
• Manage the department budget to ensure cost-effective operations.
• Align resources with high-priority strategic initiatives.

Job Requirements

• Current NYS RN license/registration required.
• Bachelor of Science in Nursing (BSN) required.
• Master’s degree in Nursing, Public Health, Healthcare Administration, or related field preferred.
• *Certified Professional in Healthcare Quality (CPHQ).
• *Certified Professional in Patient Safety (CPPS).
• *Lean Six Sigma certification (Green or Black Belt).

*Required certifications must be obtained within two years of employment if not already held.

Minimum Experience Requirement

• At least 5 years of experience in quality improvement in a general hospital setting.
• At least 3 years of supervisory experience in a general hospital setting.
• Proven success leading QI initiatives with strong knowledge of the healthcare environment.

Essential Skills and Competencies

• In-depth knowledge of federal regulations and Joint Commission standards.
• Strong analytical and critical thinking skills with the ability to interpret complex data.
• Demonstrated leadership and team management skills with success in a fast-paced environment.
• Collaborative leadership style with the ability to build trust across diverse stakeholders.
• Excellent communication skills, able to present complex information clearly to varied audiences.
• Sound judgment with the ability to navigate organizational and political challenges.

Physical Requirements / Working Conditions

• Sedentary work: lifting up to 10 lbs. occasionally; primarily sitting with some walking and standing.
• External applicants and current employees who become disabled must be able to perform essential functions with or without reasonable accommodations, determined on a case-by-case basis.

Position is fully onsite Monday - Friday.

Samaritan is an Affirmative Action/Equal Opportunity Employer. Women, Minorities, Disabled, and Veterans are encouraged to apply.

Work Shift:

Exempt (United States of America)

Position Hours:

80

Samaritan is an Affirmative Action/Equal Opportunity Employer.  Women, Minorities, Disabled, and Veterans are encouraged to apply.