Leads and directs clinical and administrative quality management activities for the organization, including accreditation and regulatory compliance, patient safety, and performance improvement. The scope of responsibility encompasses all settings of the organization. Oversees the coordination and evaluation of a comprehensive patient safety improvement program in conjunction with the Director of Quality/Performance Improvement, Patient Safety Officer, and leadership. Has oversight of conformance to regulatory requirements and coordinated accreditation and regulatory surveys. Conducts rounds to ensure ongoing survey readiness. Is a resource to departments with regulatory compliance to include state/CMS. Has a detailed understanding and can skillfully use the techniques of system design, re-engineering, project management, quality improvement, patient safety, outcomes measurement, and analysis. Qualifications Work requires the knowledge of theories, principles, and concepts normally acquired through completion of a Master's degree in Nursing or closely related field, and three to five years of previous work related experience. Licensure required as a Registered Nurse by the State of New Jersey. Certification in Healthcare Accreditation and Patient Safety preferred. Work requires the knowledge of federal and state regulations, standards, and practices for an acute care hospital. Work requires the analytic ability necessary to resolve problem requiring a professional level of knowledge in specific discipline/field and to design complex educational, clinical, data processing systems and programs. Work requires analytical ability to collect information from diverse sources and apply professional principles in performing various analyses, and summarize the information and data in order to solve problems. About the Team St. Joseph's University Medical Center is an academic tertiary care medical center and state designated trauma center, located on the Paterson campus, regularly accepts referrals of difficult or unusual cases from other hospitals and physicians and performs both complex and routine procedures. The Medical Center offers a full complement of specialty and subspecialty services including ambulatory, behavioral health, cardiovascular, emergency/trauma, internal medicine, neuroscience, oncology, orthopedic/spine, rehabilitation, surgical specialty, women's health, imaging and pediatrics. The nursing team at St. Joseph's University Medical Center, which includes St. Joseph's Children's Hospital, has held the Magnet Award for Nursing Excellence, the profession's highest honor, since 1999. They are also recipients of the prestigious 2010 Magnet Prize™ - one of only 8 Magnet-designated hospitals to ever receive The Magnet Prize, and the only one worldwide to receive the 2010 award.