EHS Director, Clinical Quality & Survey Readiness

Sutter Health   •  

Modesto, CA

Industry: Healthcare


5 - 7 years

Posted 34 days ago

This job is no longer available.

Maintains authority, responsibility and accountabilities for Quality Services, Patient Safety, performance improvement, dashboard performance, Institute for Medical Quality (IMQ) accreditation, the development, implementation, and evaluation of nursing standards of care, scope of practice, and performance. Maintains accountability for the development, implementation, and evaluation of medical assistant standards of care, scope of practice, and performance. These accountabilities include consistency across all areas of practice to ensure same standards of nursing care, clinical services, and medical assistant standards are being delivered.

Responsible for professional practice and workforce development, clinical education and training; leadership; research, innovation and evidence-based practice; and quality improvement program execution for all clinical staff.

Advances excellence in practice to promote high-reliability systems, continuous improvement and learning culture that integrates the use of technology to improve quality and service excellence applying the voice of patients and other customers.

Ensures the quality of nursing standards of patient care and practice by incorporating current nursing research findings, nationally recognized professional standards and other literature into the policies and procedures governing the provision of nursing care, treatment, and services. This position therefore establishes nursing policies and procedures, nursing standards, and nurse staffing plans that are defined, documented and accessible to the nursing staff. She/he exercises final "clinical" authority over those who provide nursing care, treatment, and services, including registered nurses, licensed vocational nurses and medical assistants and clinical services.

Ensures the application of evidence-based knowledge and data management to drive change to achieve excellence.

Responsible for the development, implementation and maintenance of systems within the department to ensure compliance with the organization, regulatory and accrediting bodies that is fiscally responsible; will provide clinical leadership and oversight to care center managers, directors, and the Vice Presidents of Operations; will work directly with the Director of Performance Improvement to ensure dashboard performance is achieved at the highest level possible. Directs the preparation of the IMQ survey process, collaborating with the Vice Presidents of Operations, Medical Directors of Quality, Chief Medical Officers, and other leaders as necessary for a successful IMQ survey(s); will support and advance the integration of quality initiatives within the regional care centers and medical groups with the patient as the center of care; will ensure regional quality initiatives are executed, utilizing a team approach for implementation; show sound judgment in business and clinical matters, and continually reflect the values and ethics of Sutter Health and the affiliate; will apprises the Director of Quality and Patient Safety, West Bay Region and affiliate leadership of issues and activities that may affect the delivery of quality care across the affiliate. The Director of Quality, Patient Safety, and Nursing Professional Practice will be knowledgeable and supportive of all Lean improvement projects and transformation initiatives throughout the affiliate.



  • Bachelor's Degree, Graduation from an accredited School of Professional Nursing, required.
  • Master’s Degree in Nursing Administration or Nurse Executive Board Certification, or equivalent education/experience, required.
  • Knowledgeable with Quality Improvement Processes, required.

Licensures and Certifications

  • Registered Nurse - State Licensure - RN, required.


  • Must have at least five years’ experience as a senior nurse executive or nurse executive board certification or five years experience at a director level.
  • Example: 5-7 years of progressive experience in professional practice, quality, patient safety, education and management experience.
  • At least 5 years experience in Quality Management Programs, with specific experience working with CQI systems for medical staff and hospital staff, CQI methodology, Lean methodology, and Joint Commission and/or IMQ survey preparation.
  • Organizational transformation and realignment experience required.
  • Extensive experience with capitated health care programs required. This should encompass health plan clinical operations, contracting and network administration, familiarity with clinical and financial metrics for capitated programs, quality improvement, compliance with governmental regulations and health plan compliance requirements, medical management, case management, especially for high-risk populations, clinical risk management, disease management and patient education.