The Director, Quality and Patient Safety is responsible for all aspects of Quality, Clinical Risk Management and Patient Safety for their assigned entity. This individual will coordinate performance improvement activities, facilitate process and/or system changes to enhance patient safety, and collaborate with the network partners to enhance the delivery of quality and safe patient care across the continuum. JOB DUTIES AND RESPONSIBILITIES: • Facilitates quality and patient safety goals established by Leadership; assists in identifying benchmarks and opportunities for improvement; guides efforts towards attaining top decile performance and outcomes. • Promptly investigates actual and potential adverse clinical events at assigned entity, including those reported via the Patient Safety Hotline. • Analyzes actual and potential adverse clinical events at assigned entity for risk prevention and mitigation initiatives utilizing root cause/intense analysis process. • Coordinates implementation of Patient Complaint and Grievance process at assigned entity. • Reviews patient complaints and grievances and offers recommendations to effectively mitigate organizational risk. • Oversees entity Infection Control Preventionist at assigned entity, directly and/or in a matrix reporting model with the Network Manager of Infection Control and Prevention • Collaborates with Network Standards and Accreditation to assure compliance with regulatory and accrediting organizations • NJ based position is responsible for NJ regulatory compliance for hospital and other NJ DOH licensed locations. Coordinates licensure surveys and complaint investigations. • Facilitates/leads organizational improvement activities utilizing the PDCA methodology. Recommends tools and assists teams throughout the improvement process. • Provides education, consultative services and/or technical assistance to Practice leaders, Performance Improvement Committees, Service line improvement teams and others. • Conducts concurrent review of the literature and websites to provide teams and Service Lines with up-to-date evidence and best practice recommendations. • Works in a collaborative manner with physicians, administrators, practice managers and others to identify and meet the continuous performance improvement requirements of the organization. • Collaborates with Decision Support staff to determine performance metrics for key process and performance improvement initiatives. • Analyzes data reports and implements process to achieve improved performance. • Additional duties and responsibilities as assigned PHYSICAL AND SENSORY REQUIREMENTS: Sitting for up to 7 hours per day, 2 hours at a time. Frequently uses fingers for typing, data entry, etc. Frequent use of hands. Extensively uses mouse as a computer entry device. Uses upper extremities to lift up to 10 pounds. Rarely stoops, bends, or reaches above shoulder level. Hearing as it relates to normal conversation. Seeing as it relates to general vision, peripheral vision and near vision. EDUCATION: Bachelor’s degree in nursing or healthcare related field is required. Master’s Degree preferred or in progress with an identified completion date within 4 years. Certified Professional in Healthcare Quality (CPHQ) or Certified Professional in Healthcare Risk Management (CPHRM) or appropriate alternative within 2 years of hire required. TRAINING AND EXPERIENCE: Minimum of 3-5 years' experience in clinical care of patients required. Experience preparing comprehensive written reports and making effective training/education presentation. Excellent project management skills. Current professional licensure in New Jersey or Pennsylvania, based on work location. Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!!