The Director of Patient Safety (“Director”) reports to the Vice President, Quality and Safety and serves as a subject matter expert in continuous quality improvement, patient safety, and high reliability principles. In collaboration with the Director of Quality, this role leads the operational implementation and sustainment of quality and patient safety programs, driving the adoption of standardized processes and advancing a culture of safety, accountability, and performance excellence.

The Director provides operational leadership for core patient safety programs, including the Safety Reporting System (SRS), patient safety event management, root cause analysis (RCA), and peer review, applying evidence-based methodologies to identify trends, mitigate risk, and drive sustainable improvement. The role promotes systems thinking across Baystate Health through standard work, data-driven decision-making, and disciplined problem-solving, partnering with clinical and operational leaders to close gaps, ensure accountability, and align quality, safety, and regulatory priorities.

At the local hospital, this position is responsible for the oversight of regulatory and external reporting requirements, including submissions to the Board of Registration in Medicine Patient Care Assessment Program (PCAP), The Joint Commission, the Massachusetts Department of Public Health (DPH), and other internal and external stakeholders. The Director ensures accuracy, timeliness, and alignment of reporting with organizational priorities and regulatory expectations.

1.Patient Safety Program Operations & Event Management

•             Lead the day-to-day oversight of Baystate Health operations of the Safety Reporting System (SRS), ensuring timely review, triage, and follow-up of patient safety events.

•             Identify trends, patterns, and emerging risks, escalating issues appropriately and coordinating cross-functional responses.

•             Facilitate RCAs, apparent cause analyses, and other structured investigations, ensuring actionable recommendations and follow-through on improvement plans.

•             Conduct audits and compliance reviews to identify gaps and ensure adherence to standards, implementing corrective actions as needed.

•             Ensure learning is disseminated across teams and that action plans are implemented, monitored, and sustained.

2. Systems Thinking & Improvement Support

•             Provide consultative support to leaders and teams in structured problem-solving, PDSA cycles, RCA, and other performance improvement methodologies.

•             Facilitate data collection, validation, and analysis to inform improvement priorities and operational decision-making.

•             Assist departments in aligning workflows, policies, and procedures with current practice, regulatory requirements, and evidence-based standards.

3. High Reliability & Culture of Safety

•             Operationalize High Reliability Organization (HRO) principles through structured processes that promote safety, transparency, accountability, and learning.

•             Reinforce Just Culture principles and support leaders in creating psychologically safe environments that encourage reporting and continuous improvement.

•             Contribute to the development and sustainment of a culture of safety through education, coaching, and integration into daily operations.

4. Integration, Standardization & Alignment

•             Facilitate the development, implementation, and sustainment of standard work across departments to ensure consistency, reliability, and clarity of expectations.

•             Monitor adherence to standard work through audits, performance reviews, and structured escalation processes.

•             Support alignment of quality initiatives, patient safety priorities, and operational goals across departments and sites.

•             Support implementation of organizational patient safety and quality strategies in alignment with leadership direction.

•             Participate in special projects, system initiatives, and cross-entity improvement efforts as assigned.

5. Quality & Regulatory Program Alignment

•             Support the management, coordination, validation, and submission of required clinical and quality data, ensuring data integrity and completeness in collaboration with the Director of Quality.

•             Monitor and provide oversight for regulatory and accreditation reporting requirements, ensuring compliance with PCAP, CMS, DPH, Joint Commission, Leapfrog, and payer-based programs.

•             Support Joint Commission readiness, including coordination of mock tracer activities, standards interpretation, and survey preparedness efforts.

6. Visual Management & Tiered Communication

•             Promote transparency using visual management systems and performance dashboards to support situational awareness.

•             Provide leadership and oversight of tiered huddle processes, ensuring effective communication, escalation pathways, and alignment across units and departments.

7. Collaboration & Stakeholder Engagement

•             Build and maintain effective working relationships with clinical leadership, physicians, operations, finance, and support services to advance quality and safety goals.

•             Facilitate interdisciplinary collaboration to address system-level issues and support coordinated performance improvement efforts.

•             Partner with system and regional leaders to ensure consistency in program implementation and communication.

8. Staff Supervision & Workforce Development

•             Direct and supervise Quality & Safety Specialists, including performance evaluation, orientation, and development.

•             Support staff skill-building in patient safety and high reliability, RCA facilitation, utilization of evidence-based improvement methodologies, and data analysis.

•             Address personnel issues and ensure alignment with departmental and organizational expectations.

•             Contribute to workforce planning and competency development in alignment with organizational needs.

Quality & Performance Excellence

• Quality Improvement Methodologies

• Systems Thinking & Process Design

• Regulatory & Accreditation Knowledge

• Data Analysis & Performance Measurement

Patient Safety & Risk Management

• Event Review & Investigation

• Just Culture & HRO Application

• Risk Identification & Escalation

• Learning from Defects

Leadership & Execution

• Program Implementation

• Cross-functional Collaboration

• Change Management & Coaching

• Communication & Influence

• Bachelor of Science      

• Clinical degree with active professional licensure  ​

• Required Experience:  Minimum of five (5) years of progressive experience in healthcare quality, patient safety, or performance improvement.

• Strong knowledge of clinical operations and healthcare systems

• Demonstrated leadership, facilitation, and project management capabilities

• Proficiency in quality improvement methodologies and data analysis

• Master’s degree in public health, healthcare administration, business administration, or related field

• Certification in Healthcare Quality, Patient Safety, or related specialty (CPHQ, CPPS)

• Experience with regulatory reporting, accreditation readiness, and patient safety programs (preferred)

Education:

Certifications:

Compensation

Note: The compensation range(s) in the table below represent the base salaries for all positions at a given grade across the health system. Typically, a new hire can expect a starting salary somewhere in the lower part of the range. Actual salaries may vary by position and will be determined based on the candidate's relevant experience. No employee will be paid below the minimum of the range. Pay ranges are listed as hourly for non-exempt employees and based on assumed full time commitment for exempt employees.

Minimum - Midpoint - Maximum