Director of Clinical Quality & Patient Safety (RN)

The Director of Clinical Quality & Patient Safety (RN) is a high-impact, experienced executive leader accountable for providing comprehensive strategic oversight and guidance for all clinical quality, patient safety, and regulatory compliance programs across the assigned service area. This Director must possess a Registered Nurse (RN) license and expert experience in High Reliability Organization (HRO) principles. The role drives superior clinical outcomes by directing accreditation efforts, championing evidence-based medicine, managing critical safety events, and partnering directly with medical staff leadership to ensure best-in-class performance and regulatory compliance.

Required Qualifications & Experience

Must-Haves (Critical Skills & Credentials)

• RN (Registered Nurse) License (Required due to the clinical nature of the oversight).

• HRO (High Reliability Organization) Training/Experience.

• CPHQ (Certified Professional in Healthcare Quality) or equivalent Quality Certification (required within 24 months of hire).

• Master's Degree in Business, Health Care, Public Administration, or a directly related field.

• 10 years of experience in quality or clinical settings, specifically with Clinical Quality management experience.

Core Responsibilities & Expertise

• Strategic & Operational Quality Leadership: Provide strategic leadership and management for all quality initiatives, ensuring the use of Evidence-Based Guidelines and Daily Management Systems (DMS) to optimize clinical outcomes.

• Regulatory Compliance: Direct and manage all accreditation, licensing, and regulatory activities, ensuring system-wide compliance and maintaining continuous survey readiness with bodies like Joint Commission, CMS, and CDPH.

• Risk & Safety Management: Oversee and be accountable for all patient safety programs. Direct overall risk management efforts, including serving as the primary contact during significant event management and utilizing tools like Root Cause Analysis (RCA) and Failure Mode and Effect Analysis (FMEA) to mitigate future clinical risk and medical errors.

• Infection Control: Direct and oversee infection prevention and control programs, including consulting on environmental design and managing outbreak containment.

• Data-Driven Decision Making: Act as a subject matter expert in interpreting clinical data, claims, and vital statistics to guide long-term strategy. Oversee systems for data management and ensure the quality improvement monitoring agenda is data-driven.

• Team Leadership: Experience leading teams, fostering talent development, and partnering with medical staff to support peer review and practitioner performance.

Experience (Minimum Years Required)

• Minimum ten (10) years of experience in clinical and management roles in a healthcare setting.

• Minimum nine (9) years of experience in a leadership role (with or without direct reports).

• Minimum four (4) years of experience managing operational or project budgets.

Preferred Skills

• Performance Improvement (PI) trainings or certifications (e.g., Lean, Six Sigma).