Director Quality and Patient Safety

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The Director of Quality and Patient Safety serves as a strategic leader dedicated to advancing clinical excellence, patient safety, and organizational performance. This role integrates oversight of quality and safety initiatives with operational leadership, ensuring compliance with regulatory standards, promoting evidence-based practices, and fostering a culture of high reliability and continuous improvement. Partnering with clinical and administrative leaders, the Director develops and implements process measures that drive superior outcomes, strengthen patient safety, and align with organizational goals for quality and service line growth.

Strategic Leadership & Program Development

• Drive organizational strategy by developing and executing comprehensive project and program plans aligned with organizational and service line goals.
• Advance clinical excellence through initiatives that standardize practice, reduce variability, and improve patient outcomes using evidence-based guidelines.
• Influence strategic direction by contributing to annual planning and presenting program metrics and initiatives to all levels of leadership.

Quality & Patient Safety Oversight

• Design and implement patient safety initiatives; monitor and analyze quality metrics, including root cause analyses and post-event action planning.
• Lead quality teams, set agendas, and drive accountability for performance improvement, regulatory readiness, and patient safety.
• Champion a culture of safety, transparency, and continuous learning to achieve zero harm.

Regulatory Compliance & Continuous Readiness

• Ensure compliance with standards from The Joint Commission, CMS, NJDOH, OSHA, and other governing bodies.
• Conduct rounding and readiness assessments for accreditation surveys and inspections.
• Lead comprehensive rounding and proactive readiness evaluations to ensure continuous compliance with accreditation standards and regulatory requirements, identifying gaps and driving corrective actions to maintain survey and accreditation readiness at all times.
• Provide education and training to clinical teams on quality, safety, and regulatory requirements.

Data Analysis & Performance Monitoring

• Analyze data from internal and external sources to identify trends, benchmark performance, and develop action plans.
• Facilitate discussions for program improvement and present findings to stakeholders.

Collaboration & Advocacy

• Serve as liaison to quality collaboratives, regulatory agencies, and accreditation organizations.
• Engage with medical directors, department chairs, and operational leaders to advance service line initiatives.

Required Experience
: 5 years of experience as a professional nurse or equivalent clinical profession with 3 years recent clinical experience in a specialty related area. Must be proficient in Excel, Word, Outlook and PowerPoint with the ability to present data in a variety of ways.

Required Education
:
Bachelor’s in Nursing required. Masters Degree preferred.

Training / Certification / Licensure
: RN licensure required (as applicable); certification in healthcare quality or specialty preferred (e.g., CPHQ, CPPS, CNOR, Baby Friendly) or must be obtained in one year; certifications per hiring department requirements.