Job Description

The Director Quality, Patient Safety, and Accreditation is responsible for leading the comprehensive quality, safety, and performance improvement program at Anderson Hospital. 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.

Minimum Qualifications

• Education: Bachelors Degree (required) or Masters Degree (preferred)
• Licensure/Certifications:
• Registered Nurse (required) – will consider other clinical license
• Certified Professional in Healthcare Quality (CPHQ) (required) or obtain within one year of hire
• Certified Professional in Patient Safety (CPPS) (preferred)
• Experience: 5 years of Clinical Experience
• Experience in quality and performance improvement work
• Regulatory and accreditation processes
• Leading and developing teams

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