Job Summary:
Provides strategic leadership to advance organizational excellence in safety, quality, performance, and clinical outcomes. Oversees programs that prevent harm, strengthen a culture of high reliability, promote continuous learning, and drive measurable performance improvement across the organization. Partners with executive leadership, physicians, clinical staff, and system-level teams to deliver a unified approach to patient safety, performance improvement, and quality outcomes. Serving as a key advisor to executive leadership and the Board the Director sets vision and priorities, directs improvement initiatives, and ensures accountability, transparency, and sustainable results throughout the organization.
Job Requirements:
Education and Work Experience:
- Bachelor's degree in Health Care Administration, Nursing, Public Health, or related field or equivalent combination of education/related experience: Required
- Seven years' of health care or related experience: Required
- Five years' leadership experience in quality, patient safety, performance improvement, or healthcare administration: Required
- Leadership experience in acute care quality, patient safety, and/or performance improvement: Preferred
- Clinical background: Required
Licenses/Certifications:
- Certified Professional in Healthcare Quality (CPHQ) or Certified Professional in Patient Safety (CPPS) certification or Lean Six Sigma Green Belt: Required within two years of hire
- Certified Professional in Healthcare Quality (CPHQ) or CPPS or Lean or Six Sigma Green Belt (LGB): Required
Essential Functions:
- Partners with executive leaders and the Board to establish strategic priorities for quality, safety, and performance improvement. Provides expert consultation on quality systems, patient safety practices, and national performance standards. Champions integrity, transparency, and continuous improvement in organizational performance.
- Leads deployment of the Patient Safety Plan, Patient Safety Program, and Safety Event Review Team. Directs high reliability skills training deployment and patient safety program, including: oversight of the AH Reporting and Learning System; root cause analysis and action; rapid response to high-risk events; and proactive risk assessments. Fosters a culture of safety by overseeing the Culture of Safety Survey results and action plans; serving as a resource for Just and Accountable Culture principles; and promoting health equity, patient and family engagement in safety, the Communication and Resolution Program and the Care for the Caregiver program. Develops and monitors safety goals and associated metrics, including the aspirational goal of zero preventable harm. Prioritizes and directs improvement projects to drive results. Assists Regulatory and Accreditation leaders to promote continuous readiness for accreditation and regulatory surveys.
- Provides leadership for QAPI and other organization wide performance improvement initiatives designed to reduce preventable harm, improve patient outcomes, streamline workflows, and optimize operational efficiency. Establishes structures, processes, and accountability mechanisms that ensure consistent application of performance improvement methods across departments and service lines. Advances Lean, Six Sigma, and other performance improvement methodologies by delivering training, coaching leaders and staff, and overseeing the execution of improvement projects from design through sustainability. Facilitates multidisciplinary collaboration to identify gaps in care, remove barriers, and implement evidence-based best practices that drive measurable improvement. Regularly monitors, analyzes, and reports organizational performance data to identify trends, benchmark against national standards, and inform executive decision-making. Aligns performance improvement initiatives with organizational goals and national benchmarks. Recognizes and celebrates achievements to reinforce a culture of continuous improvement and accountability.
- Recruits, mentors, and develops Quality and Patient Safety staff to build internal expertise and leadership pipelines. Fosters interdisciplinary collaboration with physicians, nursing, and operations leaders to drive evidence-based practice adoption. Partners with system and facility leaders to deliver education on quality and safety standards.
- Partners with System Quality and Patient Safety to oversee data systems that capture, analyze, and report quality, safety, and performance improvement outcomes. Partners with System Quality and Patient Safety to ensure accurate and timely submission of required reports to internal committees, external registries, and regulatory agencies. Presents actionable insights and recommendations to leadership and the Board, driving accountability for results.
- Performs other job-related duties as assigned.
Organizational Requirements:
Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.
