Catholic Health Initiatives Director-Quality-Patient Safety, Quality Risk and Safety Department, Sts Mary and Elizabeth Hospital in LOUISVILLE, Kentucky

Director-Quality-Patient Safety, Quality Risk and Safety Department, Sts Mary and Elizabeth Hospital


1st Shift, Full Time

Job Summary / Job Purpose

The Director of Quality and Patient Safety is responsible for the design, supervision and maintenance of a facility-based comprehensive Quality and Safety program. The Director plans, directs, implements and

evaluates quality, safety and experience strategies to ensure a well-planned and systematic program for the facility. The Director‟s work focuses on influencing and facilitating aspects of clinical effectiveness, evidence based practices and quality process improvement with interdisciplinary teams, including

physicians, clinical management and other healthcare staff, ensuring consistency of best practice implementation and providing oversight and ongoing performance monitoring and action plans on key metrics. The position monitors the facility based quality, safety and service outcomes on a number of key measures, including Living our Mission Measures (LOMM) and helps develop local action plans to enhance improvement efforts. As a part of a „Quality Triad‟, the Director partners with the Chief Medical

Officer and Chief Nursing Officer to support a comprehensive program to improve patient outcomes and minimize patient harm through the implementation of processes and systems that support a consistent,

standardized culture of quality and safety.

The Director leads the planning, organizing and managing of activities and programs related to regulatory readiness. The position partners with operational leaders to direct processes related to ensuring environmental and facility based safety is aligned with regulatory and other accrediting standards. The Director provides leadership for educational programs related to quality and safety and

serves as an internal consultant and subject matter expert to the facility based medical staff, administration, all hospital departments and committees to carry out all functions related to Quality. The Director provides leadership and oversight of division‟s quality and patient safety staff and ensures

consistent communication and committee forums are in place to ensure mechanisms for reporting and information sharing. The position facilitates the establishment of a data driven culture in the clinical quality and operational areas.

The Director of Quality and Patient Safety provides collaborative oversight of the work product that includes Patient Safety & SafetyFirst Program, Clinical Performance Improvement, Infection Prevention, Accreditation and Regulatory Compliance, Quality Improvement (peer review), Risk Management and

Data Analytics / Abstraction / Reporting operations.


Job Requirements / Qualifications

Education /Accreditation / Licensure (required & preferred):

  • Bachelor‟s degree in nursing or a clinical or healthcare related field required. (ie: health care administration, business administration, public health)

  • Master‟s degree highly preferred

  • Registered Nurse, clinical licensure preferred.

  • Nationally recognized quality-related certification (ie: CPHQ, PMP, CJCP, CPPS) preferred

  • Working knowledge of National Quality Forum (NQF), Agency for Healthcare Research and Quality (AHRQ), Institutes for Healthcare Improvement (IHI) safety indicators, serious reporting events, safe medical practices, and Centers for Medicare and Medicaid Services (CMS) quality measures helpful

Experience (required and preferred):

7 years of relevant clinical and quality experience

  • Experience in quality improvement principles, performance improvement methodology, project management and change management required

  • Knowledge of regulatory and accrediting standards and Medical Staff Office preferred

  • Previous experience in preparing and presenting professional presentations preferred

  • Patient safety experience and work with High Reliability Organizations / Systems preferred

5 years of leadership experience required


  • Experience with Cerner, Allscripts, Meditech and other EHR software systems a plus

  • Strong Information Technology - informatics knowledge a plus

Job Director/Manager/Supervisor


Daily Schedule 1

Scheduled Hours per 2-week Pay Period 80

Weekends Required Occasional

Req ID: 2018-R0185743

We’re 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.