Facility

Cape Fear Valley Medical Center

Location

Fayetteville, North Carolina

Department

Quality & Patient Safety

Job Family

Management

Work Shift

Days (United States of America)

Summary

Assist with design and developing the scope of Cape Fear Health System's Quality and Patient Safety Program. Facilitate and ensure the systematic evaluation of medical services in accordance with predetermined standards. Serve as a resource person for all Medical Center Departments and as a liaison between the Medical Center and the Medical Staff. Responsible for Safety Programs throughout the health system, including obtaining and maintaining disease/Specialty specific accreditations. Perform duties and responsibilities in a manner consistent with the mission and vision of Cape Fear Valley Health System.

Major Job Functions

The following is a summary of the major essential functions of this job.  The incumbent may perform other duties, both major and minor, that are not mentioned below.  In addition, specific functions may change from time to time:

• Design, develop and implement an effective Quality and Patient Safety Program within the guidelines of the approved Quality and Patient Safety Improvement Plan and the Joint Commission Standards
• Review Quality and Patient Safety Improvement Plan and programs with the Quality Management Board
• Coordinate all performance improvement activities within Cape Fear Valley Health System to maintain proper communication, focus on existing or potential opportunities for improvement and prevent duplication of events among all phases of performance improvement activities
• Collect and review quarterly quality improvement reports and prepare summary for the Board of Trustees
• Communicate and facilitate the integration of Performance Improvement activities of the Medical Center, Medical Staff, and other departments
• Ensure the Medical Center complies with outside regulatory agency standards as they relate to Performance Improvement activities and keep abreast of all changes and recommendations relating to The Joint Commission
• Maintain all information in a manner which ensures confidentiality and establish organized systems for data retention and retrieval
• Coordinate and/or provide staff development programs relating to Performance Improvement
• Actively participate in professional groups, such as the NCAHQP and NAHQP
• Serve on Medical Center committees as appropriate
• Provide leadership within the senior nursing team to support patient/family centered care delivery and transformation of the nursing culture to consistently accountable, staff nurse lead, evidence based proactive environment
• Provide leadership in the implementation of robust nursing quality program
• Evaluate all aspects of the current quality and safety program and implement improvements to support a state of the art, comprehensive program
• Serve as an expert resource and provide ongoing education related to quality principles, systems, methods, tools, standards, adult processes data management reporting and improvement systems
• Provide leadership to health system disease specific certification initiatives, including Stroke, Hip and Knee, CHF, Acute MI, and others as determined
• Other duties as assigned

Minimum Qualifications

The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:

Education and Formal Training: 

• Bachelor’s degree required
• BSN preferred
• Certification in Six Sigma/Lean, CPHQ, CQM, CQA preferred

Work Experience: 

• 3 years’ experience in leading Quality programs/departments required
• 10 years of professional experience in quality preferred
• 1 year experience in hospital quality and safety preferred

Knowledge, Skills, and Abilities Required: 

• Proficiency in reading, writing, and speaking the English language
• Knowledge of The Joint Commission Standards and Continuous Quality Improvement methodologies
• Ability to analyze, interpret, and present meaningful data reports for departmental and clinical review
• Strong leadership, creativity, solid knowledge base in hospital operations and organizational development, financial analysis, patient safety and process improvement
• Results-oriented, excellent presentation and writing skills, keen analytical and project management skills
• Must maintain a high level of confidentiality
• Possess tact and diplomacy when interacting with physicians and staff
• Exceptional listening, verbal, and written communication skills
• Proficiency in Microsoft Office (Word, Excel, PowerPoint)

Physical Requirements: 

• Ability to move throughout the Medical Center
• Visual acuity for reviewing data and reports, observing process flows
• Audiological acuity for monitoring group discussions and interactions
• Verbal ability is required to effectively express ideas and views to staff
• No anticipated occupational exposures to bloodborne pathogens or body fluids

#CFVH-2026

Required Licenses and Certifications

Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity