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Job Description:
Executive Director, Quality and Safety
Beverly, Addison Gilbert and Anna Jaques Hospitals
The Executive Director of Quality and Safety will play a crucial role in ensuring the highest standards of patient care, safety, and quality at Beverly, Addison Gilbert and Anna Jaques Hospitals (the Hospitals). Reporting directly to the Chief Medical Officer (CMO), this leadership position will be responsible for overseeing all operational aspects of quality and safety across the Hospitals. The Executive Director will manage a team of professionals and collaborate closely with key stakeholders to drive compliance with regulatory standards, uphold integrity, and foster a commitment to patient safety and quality care. The work will have over-arching goals.
Over-Arching Goals:
The Executive Director will oversee and ensure that the Hospitals follow the overarching goals of quality and safety to provide high quality, patient-centered care while ensuring the safety and well-being of patients, healthcare providers, and staff. These goals encompass a wide range of strategies, practices, and initiatives that aim to continuously improve the delivery of healthcare services. By focusing on these goals and implementing various strategies and practices, the Hospitals’ aims are to create an environment where the quality of care is consistently high, and patient safety is a top priority. Some key goals within the realm of quality and safety include:
1. Patient-Centered Care
2. Clinical Effectiveness
3. Safety
4. Patient and Family Engagement
5. Timeliness
6. Efficiency
7. Equity
8. Continuous Quality Improvement
9. Communication and Collaboration
10. Data-Driven Decision-Making
11. Training and Education
12. Transparency
13. Risk Management
14. Regulatory Compliance
15. Patient Safety Culturr
Essential Responsibilities including but not limited to:
1. Operational Oversight:
· Lead and provide strategic direction for all quality and safety initiatives, ensuring alignment with the hospitals’ mission and goals.
· Develop, implement, and monitor comprehensive quality and safety programs, policies, and procedures in pursuit of the overarching quality and safety goals outlined above.
· Collaborate with department and medical staff leaders and other stakeholders to integrate quality and safety measures into their respective areas.
· Oversee the development of tools and methods to aggregate, trend and summarize quality and safety data to suit the needs of the organization and stakeholders.
· Represent Quality and Safety at BILH System forums.
· Oversee the management of Quality Assessment and Improvement, Patient Safety, Risk Management, Regulatory Compliance, and Patient Relations and the Patient Grievances Process for the Hospitals.
· Communicate and report regularly to execution leadership regarding quality and safety matters and concerns.
· Oversee required reporting to the Medical Executive Committee and the Hospitals’ Board of Trustees Quality Committees.
2. Team Leadership and Management:
· Manage and mentor a team of professionals, including the Performance Improvement project managers, Quality/Safety site leaders, the Patient Experience Manager and the Regulatory and Patient Safety Manager.
· Provide guidance and support to team members, fostering a culture of teamwork, continuous improvement and accountability.
· Assure appropriate training, supervision and back-up consultation for Quality and Safety leaders and staff.
· Oversee the development of performance improvement plans highlighting all relevant high-risk, high-volume, problem prone key functions of care and treatments.
· Provide oversight of the operational aspects of the Hospitals’ health equity efforts.
3. Collaboration:
· Work closely with the Patient Safety Officer to create a seamless and integrated approach to patient safety initiatives.
· Establish strong relationships with the President, Chief Nursing Officer, Operating Officer, Chief Financial Officer, Vice President of Human Resources, and other key executives.
· Collaborate with department chairs, directors, and nursing leaders to ensure quality and safety objectives are shared, understood and met.
4. Regulatory Compliance
· Stay up-to-date with all relevant healthcare regulations, standards, and guidelines including State and Federal licensure and accrediting bodies.
· Ensure the Hospitals’ compliance with regulatory requirements related to quality, safety, and patient care.
5. Quality Improvement:
· Drive continuous improvement initiatives to enhance patient care outcomes, minimize errors, and optimize processes.
· Analyze data, trends, and performance metrics to identify areas for improvement and develop action plans.
· Oversee the development of comprehensive sets of clinical quality performance measures for system and local quality/safety goals.
· Oversee the establishment and tracking of quality patient outcomes.
· Support the development of clinical pathways and processes that ensure the highest quality of care across the patient care journey at the Hospitals.
6. Integrity and Patient Safety:
· Provide oversight and strategies to increase the safety of colleagues and patients at the Hospitals including the training/education and best practice implementation of said practices.
· Oversees the design and utilization of protocols and processes to enhance communication and reduce the chance of clinical errors and improve patient safety.
· Uphold the highest standards of integrity and ethical behavior, fostering a culture of trust, and transparency.
· Champion patient safety as a fundamental principle, promoting a safe and secure environment for patients, families, and staff.
· Ensure the establishment and ongoing maintenance of a safety reports process, review of sentinel events and root cause analyses.
· In partnership with the Patient Safety Officer, provide oversight of the Sentinel Event Decision Group (SEDG)
7. Patient Experience
· Oversee the Hospitals’ Patient Experience strategy and improvement work.
8. Infection Prevention and Control
· Provide “dotted line” oversight and support to the onsite Infection Prevention and Control team.
Minimum Qualifications:
· Master's degree in Healthcare Administration, Business Administration, Public Health, Nursing, or related field, with demonstrated results in the area of Quality and Patient safety in a complex academic and community hospital healthcare system.
· Extensive experience in healthcare leadership, with a minimum of 5 years in a senior management role focusing on quality and safety.
· In-depth knowledge of healthcare regulations, accreditation standards, and industry best practices.
· Proven track record of successfully leading quality improvement initiatives and driving cultural change.
· Exceptional leadership, communication, and interpersonal skills to collaborate effectively across diverse teams and stakeholders.
· Strong analytical, problem-solving abilities and project management oversight skills, with the capacity to make data-driven decisions.
· Commitment to patent safety, quality care, and continuous improvement.
· Relevant certifications (e.g., Certified Professional in Healthcare Quality, Certified Professional in Patient Safety) are a plus.
Organizing Structure: Report to Chief Medical Officer
Key Relationships:
· President.
· Patient Safety Officer
· Chief Operating Officer.
· Chief Financial Officer
· Chief Nursing Officer
· Vice President of Human Resources
· Department Directors and Associate Chief Nursing Officers
· Medical Staff Department Chairs
Pay Range:
$187,200.00 USD – $228,800.00 USD
The pay range listed for this position is the annual base salary range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law.
