Reporting to the Chief Medical Officer and working in close partnership with the Chief Nursing Officer, Hospital President, medical staff leadership, and operational leaders, the Director of Quality & Safety is responsible for leading and overseeing a comprehensive quality, patient safety, regulatory, risk management, infection prevention, and patient experience program at Anna Jaques Hospital.
The Director will collaborate with clinical, operational, and physician leadership to advance the hospital's strategic quality agenda through leadership, education, data-driven performance improvement, and project management initiatives. The overarching goal is to improve clinical outcomes, operational performance, patient experience, service excellence, and patient safety while fostering innovation and the adoption of industry best practices.
This leader will oversee hospital-wide performance improvement activities, patient safety initiatives, infection prevention and control, regulatory readiness, accreditation compliance, risk reduction strategies, and patient experience improvement efforts. Through collaboration with multidisciplinary teams, the Director will promote a culture of continuous improvement, accountability, transparency, and high reliability.
The Director serves as an internal consultant and subject matter expert for quality improvement, patient safety, regulatory compliance, and patient experience. This role is responsible for implementing and monitoring programs designed to ensure the safe delivery of care across all clinical and operational processes while cultivating a culture in which safety, quality, and exceptional patient-centered care are organizational priorities.
In partnership with executive leadership, the Director will develop, operationalize, and monitor outcome measures related to quality, safety, regulatory performance, and patient experience. The Director will lead efforts to analyze, prioritize, implement, evaluate, and communicate performance improvement initiatives that support Anna Jaques Hospital's strategic goals and commitment to clinical excellence.
Job Description:ESSENTIAL DUTIES & RESPONSIBILITIES (including but not limited to):Quality, Safety & Clinical Excellence
- Lead and oversee hospital-wide quality improvement, patient safety, and performance excellence initiatives.
- Develop and support systems for tracking, evaluating, reporting, and improving quality and patient safety outcomes,
- Collaborate with physicians, nursing leadership, and operational leaders to reduce preventable harm and improve clinical outcomes.
- Provide consultation, education, and coaching to leaders and frontline staff regarding quality improvement methodologies, patient safety principles, and evidence-based practices.
- Promote the use of Lean, PDSA cycles, Root Cause Analysis (RCA), Failure Mode and Effects Analysis (FMEA), and other improvement methodologies.
- Analyze quality and patient safety trends and recommend action plans to improve outcomes and reduce variation in care delivery.
- Support medical staff peer review, occurrence reporting, event investigations, and corrective action planning.
Patient Experience & Service Excellence
- Lead the development and implementation of a comprehensive patient experience strategy aligned with the mission and values of Anna Jaques Hospital.
- Monitor and analyze patient experience data, including HCAHPS, Press Ganey, and other patient feedback measures, to identify opportunities for improvement.
- Partner with clinical and operational leaders to improve patient engagement, communication, responsiveness, and overall patient satisfaction.
- Promote a culture of patient- and family-centered care throughout the organization.
- Develop and implement service excellence initiatives designed to enhance the patient, family, and caregiver experience across the continuum of care.
- Facilitate patient experience improvement projects and ensure accountability for achieving organizational goals and benchmarks.
Regulatory & Accreditation Readiness
- Lead and coordinate organizational readiness efforts to ensure compliance with standards established by The Joint Commission, Centers for Medicare & Medicaid Services (CMS), Massachusetts Department of Public Health, and other regulatory agencies.
- Foster a culture of continuous survey readiness and regulatory compliance across the organization.
- Partner with operational and clinical leaders to ensure understanding of regulatory requirements and accountability for sustained compliance.
- Coordinate regulatory surveys, audits, corrective action plans, and follow-up activities.
Infection Prevention & Risk Reduction
- Provide oversight of the Infection Prevention and Control Program to ensure compliance with regulatory and evidence-based standards.
- Collaborate with clinical leadership to reduce healthcare-associated infections and improve patient safety outcomes.
- Support risk management activities and initiatives aimed at reducing organizational risk and improving safety culture.
Data Analytics & Reporting
- Oversee quality, safety, patient experience, and performance reporting programs.
- Lead data collection, validation, analysis, benchmarking, and public reporting efforts.
- Present performance data, trends, and recommendations to executive leadership, medical staff committees, governing boards, and frontline teams.
- Monitor performance metrics related to:
- Clinical quality outcomes
- Patient safety indicators
- Infection prevention measures
- Patient experience (HCAHPS, Press Ganey)
- CMS quality programs
- Leapfrog initiatives
- Commercial payer quality incentive programs
- Organizational strategic goals
Leadership & Collaboration
- Facilitate multidisciplinary committees, forums, and workgroups focused on quality, safety, regulatory compliance, and patient experience.
- Build collaborative relationships with physicians, nursing leaders, department directors, and external agencies.
- Serve as a change agent who promotes innovation, accountability, transparency, and continuous improvement.
- Develop educational programs and learning opportunities to advance quality, safety, and patient experience competencies across the organization.
- Participate in strategic planning and organizational initiatives supporting operational and clinical excellence.
- Assume accountability for departmental budget planning, resource management, and program effectiveness.
QUALIFICATIONS:EDUCATION- Bachelor's degree in Nursing, Healthcare Administration, Public Health, or related healthcare field required.
- Master's degree in a healthcare-related discipline preferred.
- MA Registered Nurse license is required
EXPERIENCE- Minimum of 8-10 years of progressive leadership experience in healthcare quality, patient safety, regulatory compliance, accreditation, or performance improvement.
- Demonstrated experience leading hospital-wide quality, patient safety, and patient experience initiatives.
- Experience with The Joint Commission, CMS, state regulatory requirements, and accreditation processes.
- Strong understanding of healthcare quality metrics, performance improvement methodologies, and patient experience strategies.
OTHER REQUIREMENTS:- Exceptional leadership and relationship-building skills.
- Strong analytical skills with the ability to interpret, present, and utilize data to drive organizational improvement.
- Outstanding communication and presentation skills with the ability to influence stakeholders at all levels.
- Proven ability to lead organizational change and foster a culture of safety, quality, and service excellence.
- Demonstrated success managing complex projects and multidisciplinary teams.
- Commitment to patient-centered care and continuous improvement.
- Consistently promote a culture of Wellbeing, Empathy, Collaboration, Accountability, Respect, and Equity as outlined in the organization's WE CARE values.
- Demonstrated commitment and actions to valuing diversity and contributing to an inclusive working and learning environment
Pay Range: $150,000.00 USD - $190,000.00 USD
The pay range listed for this position is the annual base salary range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law.
