Director - Patient Safety and Accreditation


Advance a patient safety program that promotes a culture of safety and the elimination of avoidable harm. Ensure organizational ongoing compliance and readiness for external regulatory agencies including, but not limited to, The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS). Ensure a robust and timely response to patient grievances and analyze to identify and address improvement opportunities.

Graduate of an accredited RN School of Nursing or bachelor's degree in health related field required. Master's preferred.

Certification in Patient Safety (CPPS) required; if not already CPPS, must obtain certification within 12 months of hire.

Healthcare Accreditation Certified Professional (HACP); if not already HACP, must obtain certification within 12 months of hire.

Strong analytical abilities with proficiency in Excel, PowerPoint, MIDAS (or related quality database). Quality Management skills including flow charting, team facilitation, data analysis, and report generation. Skilled at Root Cause Analysis (RCA), Failure Mode Effects Analysis (FMEA) and Plan-Do-Study-Act Rapid Cycle Improvement (PDSA).

Three (3) years healthcare experience in patient safety, risk, and/or quality. Healthcare experience should be recent and within a clinical setting such as Hospital, Ambulatory Surgery Center, etc. Five (5) years healthcare experience in patient safety, risk, and/or quality preferred.