DIRECTOR OF QUALITY IMPROVEMENT AND PATIENT SAFETY

Location:

Samaritan Medical Center

Department:

01.8742 SMC HEALTHCARE RESOURCE

Pay Range:

49.10 - 65.06

Care for our community, and your career.

The Director of Quality Improvement and Patient Safety reports directly to the Vice President for Medical Affairs and Chief Medical Officer (VPMA/CMO). The Director provides strategic leadership, operational direction, and continuous administrative oversight of the Quality Improvement and Patient Safety Department. This role advances patient care, clinical excellence, patient experience, and zero preventable harm in direct alignment with Samaritan Medical Center's mission, vision, and strategic priorities.The Director serves as the organizational operational authority for clinical quality improvement, high reliability methodologies, patient safety science, and regulatory readiness. In partnership with the Chief Medical Officer, nursing executive leadership, medical staff leadership, and operational directors, the Director identifies priority quality and safety metrics, recommends annual improvement targets, executes targeted clinical interventions, and monitors performance against national benchmarks.A primary mandate of this position is to drive measurable, sustained progress toward top decile clinical performance, advance Samaritan Medical Center's Centers for Medicare and Medicaid Services (CMS) Hospital Overall Star Rating toward four stars and above, optimize performance under the CMS Value Based Purchasing (VBP) and Hospital Acquired Condition Reduction Program (HACRP), and elevate national safety evaluations, including the Leapfrog Hospital Safety Grade. The Director identifies systemic performance gaps, deploys evidence based improvement sciences, and embeds a robust Just Culture and high reliability mindset across clinical and administrative operations.Additional responsibilities include establishing departmental budgets, optimizing resource allocation, managing daily department operations, mentoring and advancing staff competencies, participating in the administrative on call rotation, and directing rapid response investigations for serious clinical safety events

Section 2: Duties and Job Responsibilities

Part A: Quality Performance, Safety Science, and High Reliability

• • Lead organization wide clinical quality and patient safety initiatives designed to eliminate preventable patient harm, reduce hospital mortality, and optimize clinical outcomes.
  • Partner with the Chief Medical Officer and executive management to define annual quality metrics, establish clinical targets, and align department work plans with organizational strategic goals.
  • Direct the systematic deployment of evidence based improvement methodologies, including Model for Improvement (PDSA), Lean, Six Sigma, and Institute for Healthcare Improvement (IHI) best practice bundles across acute, ambulatory, and procedural service lines.
  • Manage and operationalize patient safety sciences, including the rigorous facilitation of Root Cause Analysis and Action (RCA2) investigations, proactive Failure Mode and Effects Analysis (FMEA), clinical risk assessments, and apparent cause evaluations.
  • Champion the institutional adoption of High Reliability Organization (HRO) principles and Just Culture algorithms; oversee the daily clinical safety briefing system, promote leadership safety walk rounds, and manage safe, non punitive near miss and safety incident reporting processes.
  • Track, evaluate, and direct institutional strategies for major national and state quality rating, benchmarking, and value incentive programs, including CMS Hospital Overall Star Ratings, CMS Value Based Purchasing, CMS HACRP, Leapfrog Hospital Safety Grade, American College of Surgeons NSQIP, and specialty clinical registries.
  • Conduct advanced statistical process control (SPC) data analysis to detect clinical trends, identify adverse variations, evaluate intervention efficacy, and deliver actionable executive reports to the Chief Medical Officer, Quality Council, and Performance Improvement Council.
• Part B: Departmental Leadership and Operational Administration
  • Provide executive administrative oversight, team mentorship, and operational management for the Quality Improvement and Patient Safety Department, functioning under the direct administrative supervision of the Chief Medical Officer.
  • Directly supervise and evaluate departmental personnel, including the Patient Safety Officer, Process Improvement Coordinator, Quality Improvement Practitioners, Clinical Data Abstractors, and Administrative Support Staff.
  • Coordinate operational workflows and ensure continuous communication among Quality, Patient Safety, Infection Prevention, Risk Management, and Case Management to eliminate clinical review silos.
  • Formulate and manage departmental operating and capital budgets, ensuring optimal resource utilization, technology modernization, and adequate staffing models.
  • Establish departmental goals, key performance indicators, and individual accountability metrics aligned with institutional safety goals.
  • Participate in the hospital administrative on call rotation and provide administrative leadership for immediate response and preliminary review of sentinel events or acute clinical crises.
• Part C: Medical Staff Quality Alignment and Governance
  • Oversee the clinical quality data infrastructure supporting Medical Staff governance, collaborating with the Chief Medical Officer to provide objective, timely, and validated clinical quality indicators for Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE).
  • Coordinate and support the Medical Staff Peer Review Committee to facilitate objective, peer level case reviews and systemic improvement tracking.
  • Serve as Chair of the Quality Council; establish data driven agendas, monitor departmental action items, track metric trends, and coordinate enterprise performance updates.
  • Serve as Chair of the Joint Commission and Regulatory Steering Committee.
  • Provide active administrative leadership and operational support to the Patient Safety Committee, Performance Improvement Council, and Medical Management Committee.
  • Serve as an active quality representative on the Infection Control Committee, Pharmacy and Therapeutics (P&T) Committee, Environment of Care/Safety Committee, and designated Medical Staff departmental meetings.
  • Prepare and present comprehensive quality and safety analyses for the Board of Trustees Quality Committee on behalf of the Chief Medical Officer.
• Part D: Regulatory Compliance, Accreditation, and Continuous Readiness
  • Serve as the organizational administrative liaison to healthcare regulatory and accreditation authorities, including The Joint Commission, the New York State Department of Health (NYS DOH), NYS DOH Office of Professional Medical Conduct (OPMC), Centers for Medicare and Medicaid Services (CMS), and the Office of Mental Health (OMH).
  • Oversee an institutional model of continuous survey readiness, executing unannounced tracer activities, environmental rounds, policy reviews, and periodic mock surveys across inpatient units and outpatient departments.
  • Direct the development, submission, monitoring, and validation of regulatory Statements of Deficiencies and Plans of Correction, ensuring root causes are eliminated and compliance is sustained.
  • Coordinate institutional investigations, clinical timelines, and regulatory correspondence for NYS DOH complaint surveys, Joint Commission inquiries, and Patient Safety Organization (PSO) disclosures.
  • Serve as the administrative point of contact for Quality Improvement Organizations (QIOs), managed care entities, and external third party payers regarding quality of care complaints and clinical validation inquiries.
• Part E: Clinical Analytics, Informatics, and Mandatory Reporting
  • Direct the accurate and timely validation, extraction, and submission of mandatory state and federal quality measures, including CMS electronic Clinical Quality Measures (eCQMs), Inpatient Quality Reporting (IQR), Outpatient Quality Reporting (OQR), and specialized clinical registry requirements.
  • Maintain data integrity and governance across quality platforms; translate complex clinical data sets into executive dashboards, unit level run charts, and service line scorecards to empower front line clinical decision making.
  • Serve as Samaritan Medical Center's NYS DOH Health Commerce System (HCS) Coordinator, supervising account provisioning, communications, institutional directory accuracy, and disaster surveillance reporting via the Health Emergency Response Data System (HERDS).
• Section 3: Job RequirementsEducation and Licensure
  • Graduate of an accredited professional nursing program with current, active licensure as a Registered Professional Nurse (RN) in the State of New York.
  • Bachelor degree in Nursing (BSN) or a related healthcare discipline is required.
  • Master degree in Nursing (MSN), Healthcare Administration (MHA), Business Administration (MBA), Public Health (MPH), or Healthcare Quality is strongly preferred. Candidates actively enrolled in an accredited graduate program with an established completion plan will be fully considered.
• Professional Certifications
  • Certified Professional in Healthcare Quality (CPHQ) or Certified Professional in Patient Safety (CPPS) is strongly preferred.
  • In the absence of active CPHQ or CPPS credentialing upon hire, the incumbent must be willing and able to attain one of these professional credentials within twenty four to thirty six months of appointment.
  • Formal training in Lean, Six Sigma, or Institute for Healthcare Improvement (IHI) methodologies is desirable.
• Experience and Required Competencies
  • Minimum of five years of progressive clinical healthcare experience in an acute care hospital environment.
  • Minimum of three years of demonstrated clinical supervisory, managerial, or program leadership experience in quality improvement, patient safety, clinical risk, nursing leadership, or regulatory compliance.
  • Working knowledge of The Joint Commission standards, NYS DOH Title 10 regulations, CMS Conditions of Participation, and public reporting systems.
  • Practical understanding of patient safety investigative tools, including Root Cause Analysis and Action (RCA2), Failure Mode and Effects Analysis (FMEA), and the application of Just Culture algorithms.
  • Demonstrated competency in clinical data analysis, statistical process control principles, electronic health record workflows, and presentation software (Microsoft Excel, Word, and PowerPoint).
  • Highly developed interpersonal, diplomatic, and communication skills, with proven ability to engage effectively with attending physicians, medical staff chairs, nursing leadership, board members, and external regulatory auditors.
  • Demonstrated ability to build multidisciplinary consensus, manage complex projects under tight operational deadlines, and navigate stressful clinical review situations with objective judgment.
  • Highest standards of personal and professional integrity, ethical conduct, objectivity, and confidentiality regarding protected health information and peer review proceedings.
• Section 4: Job Specific Information and Performance StandardsReports To Vice President for Medical Affairs and Chief Medical Officer (VPMA/CMO)Supervisory Responsibility Yes. Direct administrative and operational supervision of Quality Improvement and Patient Safety Department staff, including Patient Safety Officer, Process Improvement Coordinator, Quality Practitioners, Data Abstractors, and Administrative Support Personnel.Budget and Financial Responsibility Yes. Formulates and manages departmental operating and capital budgets.Continuum of Care Role Provides executive direction and operational leadership for hospital wide clinical quality, safety science, and regulatory compliance.Clinical Patient Contact No direct routine clinical patient contact. Frequent rounding, observational tracers, and staff engagement in patient care environments.Impact on Patients Broad, critical, and continuous institutional impact on patient safety, clinical outcomes, and care standard consistency across the entire hospital system.Internal Contacts
  • VPMA/CMO and Senior Leadership Team
  • Attending Physicians, Medical Staff Department Chairs, and Residency Program Leaders
  • Clinical Nursing Leadership and Front Line Nursing Staff
  • Pharmacy, Laboratory, Imaging, and Allied Health Leadership
  • Risk Management, Infection Prevention, Corporate Compliance, and Health Information Management
  • Board of Trustees Quality Committee members
• External Contacts
  • The Joint Commission accreditation field representatives and account executives
  • New York State Department of Health regional and central office surveyors and program directors
  • Centers for Medicare and Medicaid Services (CMS) officials
  • IPRO / Regional Quality Improvement Organizations (QIO)
  • External legal counsel, clinical consultants, peer review organizations, and benchmarking partners
• Confidential Information Extensive and mandatory access to protected health information (PHI), peer review deliberations, quality assurance committee proceedings, personnel performance records, and sensitive regulatory documents. Strict compliance with state and federal confidentiality statutes is required.Employment Classification Exempt, salaried executive management; not eligible for overtime compensation.Working Hours and On Call Responsibilities
  • Regular administrative work hours with flexibility dictated by operational and regulatory demands.
  • Participation in the administrative house on call rotation.
  • Subject to immediate emergency call back and administrative mobilization in the event of an unannounced regulatory survey, external audit, acute clinical crisis, or sentinel safety event.
• Section 5: Physical Requirements and Working ConditionsWork Environment Professional office and acute hospital environment. Requires frequent walking to patient care units, surgical suites, and outpatient departments to conduct tracers, clinical audits, and leadership rounds. Potential minimal exposure to hospital environmental hazards with appropriate adherence to standard personal protective equipment (PPE) protocols.Physical Requirements Primarily sedentary and light physical work. Must be able to sit, walk, stand, and move about the facility across multiple floors. Occasional lifting or transport of files, audit materials, or electronic equipment up to 10 pounds.Bloodborne Pathogen Exposure Category III: The direct duties of this position do not routinely involve exposure to blood, body fluids, or tissue specimens, and the employee does not deliver direct medical care. However, frequent administrative access to clinical units requires adherence to standard hospital infection prevention practices.Protected Health Information Access Level IV: Full and unrestricted access to clinical records, quality reporting systems, incident management platforms, and peer review records strictly as required to fulfill the operational responsibilities of the position.

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Samaritan is an Affirmative Action/Equal Opportunity Employer. Women, Minorities, Disabled, and Veterans are encouraged to apply. 

Tracking:

Work Shift:

Exempt (United States of America)

Position Hours:

80

Samaritan is an Affirmative Action/Equal Opportunity Employer.  Women, Minorities, Disabled, and Veterans are encouraged to apply.