Director of Quality, Safety, and Performance Excellence to lead our organization-wide approach to quality, patient safety, regulatory readiness, and continuous improvement.
In this highly visible leadership role, you will oversee the hospital's Quality Assessment and Performance Improvement program and integrated Quality Management System. You will help strengthen a culture in which safety, learning, accountability, and operational excellence are embedded in every aspect of care.
The Director will lead and develop a multidisciplinary quality, safety, accreditation, and improvement while partnering with clinical, operational, medical, and executive leaders throughout the organization. The position offers an opportunity to influence hospital-wide strategy, advance high-reliability practices, and improve outcomes for children with complex medical needs.
What You Will DoLead Quality and Performance Excellence- Provide strategic leadership and oversight for the hospital's comprehensive QAPI program.
- Lead the identification, measurement, analysis, and systematic improvement of clinical processes and outcomes.
- Develop, implement, and sustain an integrated Quality Management System aligned with ISO 9001:2015, DNV NIAHO®, and emerging accreditation frameworks, including CARF.
- Establish long-term quality priorities based on patient safety events, regulatory requirements, accreditation standards, QAPI findings, and organizational risk.
- Lead annual program evaluations and the development of hospital-wide clinical quality strategies.
- Supervise, mentor, develop, and align team members responsible for accreditation, patient safety, continuous improvement, and data.
Strengthen Patient Safety- Oversee the hospital-wide patient safety event reporting system, including timely review, escalation, and organizational feedback.
- Review and approve comprehensive Root Cause Analyses and systemic investigations following significant safety events or near misses.
- Ensure corrective and preventive actions are appropriately resourced, implemented, monitored, and sustained.
- Champion a transparent, psychologically safe reporting culture that encourages frontline engagement and organizational learning.
- Advance high-reliability principles across all departments and shifts.
Advance Continuous Improvement- Champion a hospital-wide Lean and continuous improvement strategy aligned with Ranken Jordan's strategic plan, mission, and Care Beyond the Bedside care model.
- Partner with leaders to establish meaningful key performance indicators and measurement systems.
- Help teams identify performance gaps, improve efficiency, eliminate waste, and enhance outcomes.
- Integrate Lean, Six Sigma, Agile, and improvement science methodologies into the hospital's QAPI framework.
- Facilitate complex, cross-functional process redesign and value-stream improvement initiatives.
- Provide workshops, education, and coaching that build improvement capabilities throughout the organization.
- Serve as an active member of the leadership team and lead special committees or strategic projects.
Ensure Regulatory and Accreditation Readiness- Lead year-round readiness for DNV NIAHO® surveys, CMS compliance, and CARF accreditation pathways.
- Develop and approve regulatory compliance roadmaps for new and expanding hospital services.
- Approve official Plans of Correction submitted to state and national healthcare agencies.
- Oversee regulatory commitment tracking and deadline management.
- Collaborate with Legal Services and Risk Management when quality, safety, compliance, and organizational risk intersect.
Guide Data, Measurement, and Reporting- Oversee the development, governance, validation, and reporting of quality, safety, and performance dashboards and scorecards.
- Ensure data presented to executive leadership, medical staff committees, the Board of Directors, and regulatory agencies is accurate, consistent, and timely.
- Partner with Information Technology, Data Governance, and Clinical Informatics to develop automated data-extraction processes and advanced visual analytics.
Required Qualifications- Bachelor's degree.
- Five to seven years of progressive leadership experience in hospital quality management, patient safety, or healthcare compliance.
- Advanced knowledge of QAPI, Quality Management Systems, CMS Conditions of Participation, accreditation requirements, and healthcare quality and safety practices.
- Demonstrated ability to analyze and validate complex clinical quality, safety, and performance data.
- Experience with patient safety event systems, Root Cause Analysis, and corrective and preventive action monitoring.
- Strong leadership, people-development, communication, facilitation, and organizational change capabilities.
Preferred Qualifications- Master's degree in healthcare administration, nursing, public health, or another clinical or healthcare-related field.
- Experience leading Lean or Six Sigma initiatives in a hospital setting.
- Certified Professional in Healthcare Quality, Certified Professional in Patient Safety, or a comparable professional credential.
- Knowledge of DNV NIAHO®, CARF, ISO 9001:2015, Lean healthcare, process mapping, change management, and high-reliability organization frameworks.
The position requires the ability to translate sophisticated quality, safety, risk, and performance information into clear strategies and recommendations for executive leaders, medical staff committees, and the Board of Directors.
Ranken Jordan is dedicated to serving infants, children, and adolescents with complex medical needs. This position plays an essential role in ensuring that every child receives safe, effective, patient-centered, and continuously improving care.
