Scheduled Weekly Hours:
40

Work Shift:
Days/Afternoons (United States of America)

The Facility Quality and Safety Manager is responsible for leading the comprehensive quality, safety, and performance improvement program. This includes but is not limited to oversight of safety initiatives, accreditation, infection prevention, regulatory readiness, peer review, and continuous quality improvement across the facility and associated departments. The director ensures integration of high-reliability principles and safety science to eliminate preventable harm and drive sustainable improvement.

Essential Job Functions

• Assists senior leadership in development of the strategic framework and operational plan for setting market, multi-facility, facility-wide quality and performance improvement plan and functions. Develops, implements, facilitates, and supports the development and maintenance of a robust quality, safety, and continuous improvement infrastructure to meet system quality and safety objectives and regulatory standards aligned with system objectives.
• Provides strategic leadership to collaborate and act as a resource to the facility and medical staff in the analysis and submission of data for evaluation to ensure compliance with accreditation and regulatory agencies, CMS Conditions of Participation and payor requirements - with a focus on patient safety and harm reduction.
• Provides strategic leadership and collaborates with the clinicians, administration, medical staff and department/services to assist in coordination, standardization, development of outcomes measures and continuity of quality improvement initiatives.
• Facilitates and directs the collection, aggregation, and analysis of quality and safety indicator data to provide a basis for internal and external benchmarking and performance improvement planning.
• Direct quality infrastructure to achieve organizational objectives and outcomes.
• Operationalize processes to support compliance with regulations and standards and provide oversight and accountability for guiding the facility through the regulatory survey processes.
• Supports a learning culture in driving high quality care.
• Provides strategic leadership in collaboration with medical staff and organizational leadership for oversight of the peer review and Ongoing Professional Practice Evaluation.
• Implements principles of high reliability and safety science to improve patient and associate safety throughout the facility and facilitates improvement opportunities to mitigate harm.
• Partners with key stakeholders to conduct thorough analysis of serious safety events, sentinel, events, and quality-related complaints, ensuring timely follow-up and action plans by relevant parties to prevent recurrence.
• Champions with facility leadership, a just culture and psychological safety, supporting transparency, learning from harm, and system-based improvements to protect patients and associates.

This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job related duties as required by their supervisor, subject to reasonable accommodation.

Patient Population

Not applicable to this position.

Employment Qualifications

Bachelors Degree (required)

Masters Degree (preferred)

Licensing/ Certification

Registered Nurse (required), will consider other clinical license

(CPHQ) Certified Professional in Healthcare Quality or obtain within one year of hire (required)

(CPPS) Certified Professional in Patient Safety (preferred)

Experience:

Minimum of 5 years of Clinical Experience

Working Conditions

Periods of high stress and fluctuating workloads may occur.

General office environment.

May be exposed to high noise levels and bright lights.

May have periods of constant interruptions.

Required to car travel to off-site locations, occasionally in adverse weather conditions.

Prolonged periods of working alone.

Skills

Experience in quality and performance improvement work, regulatory and accreditation processes, and leading and developing teams.

What we offer
• Competitive pay, incentives, referral bonuses and 403(b) with employer contributions (when eligible)
• Medical, dental, vision, prescription coverage, HAS/FSA options, life insurance, mental health resources and discounts
• Paid time off, parental and FMLA leave, short- and long-term disability, backup care for children and elders
• Tuition assistance, professional development and continuing education support

Benefits may vary based on the market and employment status.

Department:
SS Quality - Clinical Outcomes