Job Summary:

Reporting to the Chief Medical Officer, the Director of Quality and Patient Safety leads the development and implementation of a comprehensive quality and patient safety program that drives clinical excellence, innovation, and evidence-based practice. They ensure compliance with CMS, The Joint Commission and specialty certification program standards. The Director provides strategic leadership for quality improvement, patient safety, accreditation and certification activities. This role also assists in creating, tracking, and reporting on health equity initiatives, with a focus on minimizing disparities.

The Director collaborates closely with infection prevention, risk management, department chairs and section chiefs, the nursing department, administration, and interdisciplinary teams to identify improvement opportunities and establish reliable, consistent approaches with clearly defined objectives and metrics.

Duties and Responsibilities:

Quality and Performance Leadership

• Lead all quality management functions, including patient care quality, patient safety, regulatory compliance, and performance improvement.
• Develop and execute strategic quality plans, policies, and organization-wide improvement initiatives.
• Foster a culture of continuous improvement and data-driven decision-making.

Regulatory Compliance and Accreditation

• Oversee preparation for accreditation and certification surveys (e.g., The Joint Commission, CMS) to ensure full compliance with all regulatory and quality standards.
• Ensure ongoing adherence to state and federal requirements, including patient safety standards and documentation guidelines.
• Prepare and submit timely, accurate reports to regulatory agencies and accreditation bodies.

Data, Metrics and Reporting

• Establish and monitor quality metrics, dashboards, and data analysis systems to identify improvement opportunities.
• Ensure accurate and timely data collection and access relevant hospital databases for reporting.
• Prepare and present analyses and quality performance reports to hospital leadership and regulatory bodies.

Clinical Quality and Outcomes Improvement

• Collaborate with clinical and administrative teams to implement evidence-based practices and improve care delivery across the hospital.
• Continuously monitor clinical outcomes, enhance value, and minimize patient harm.
• Apply current clinical practice guidelines, professional standards, and regulatory requirements when evaluating patient care.
• Act as a change agent to develop and optimize processes, workflows, and training for clinical and medical staff.
• Advocate and model a Just Culture framework that encourages open reporting of incidents and near-misses without fear of retribution.

Health Equity and Value-Based Care

• Support development, tracking, and reporting of health equity initiatives.
• Integrate health equity metrics into executive dashboards to align with value-based care objectives.

Operations, Finance and Staff Leadership

• Oversee day-to-day operations related to quality and patient safety, including budgeting, financial management, and human resource management.
• Manage the budget for quality management activities to ensure effective allocation of resources.
• Supervise and support quality management staff, facilitating professional development.
• Coordinate quality and patient safety activities with stakeholders across the organization.

• Perform other related duties as assigned.

Requirements:

• Bachelor's Degree Required; Master's Degree Preferred
• Field of study: healthcare or related field
• Minimum 5 to 7 Years of leadership experience in a healthcare setting
• Certified Professional in Healthcare Quality (CPHQ) required

Care New England Health System (CNE) and its member institutions, Butler Hospital, Women & Infants Hospital, Kent Hospital, VNA of Care New England, Integra, The Providence Center, and Care New England Medical Group, and our Wellness Center, are trusted organizations fueling the latest advances in medical research, attracting top specialty-trained doctors, and honing renowned services and innovative programs to engage in the important discussions people need to have about their health.

Americans with Disability Act Statement: External and internal applicants, as well as position incumbents who become disabled must be able to perform the essential job-specific functions either unaided or with the assistance of a reasonable accommodation, to be determined by the organization on a case-by-case basis.

EEOC Statement: Care New England is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.

Ethics Statement: Employee conducts himself/herself consistent with the ethical standards of the organization including, but not limited to hospital policy, mission, vision, and values.