California Association for Healthcare Quality

Director, Patient Safety and Quality

Director, Patient Safety and Quality

Job Summary:

At NorthBay Healthcare the Director of Patient Safety and Quality in collaboration with the Assistant Vice President Quality & Care Management is responsible for overall hospital wide patient safety and quality improvement initiatives in alignment with the organizational strategic plan and goals. Has the ability and experience to present to and influence senior leaders. The Director is responsible for facilitating the transition from a retrospective, reactive model for patient safety to a prospective, proactive harm reducing patient safety program promoting the tenets of a High Reliability Organization.

This role provides direction toward safety practices and process improvements that support the mitigation of health care errors and the factors attributed to them that contribute to unintended adverse patient outcomes and conducts Root Cause Analysis as needed. Coordinates quality improvement and patient safety activities, including clinical process transformation, guideline implementation and improvement of clinical outcomes through data collection and analysis. Promotes organizational subject matter expertise in developing culture leading towards Zero Harm. Provides direct supervision and leadership of a team focused on Quality and Patient Safety.

The Director is a highly collaborative leader who can effectively design, deploy, improve and integrate reliability and improvement efforts throughout the organization. The Director plans, directs, organizes, and improves functions associated with designated NorthBay Healthcare operations in order to meet all pertinent regulatory and accreditation requirements. This position is responsible for maintaining organizational readiness and compliance to ensure that NorthBay standards, policies, procedures and practices are consistent with state and federal regulations as well as Joint Commission requirements. The Director is responsible for having strategic oversight of the Infection Prevention team and the reduction of hospital acquired infections for the health system. In addition, this position is responsible for the oversight of physician peer review. Including the continuation of peer review process redesign.

Qualifications/ Skill Requirements


Baccalaureate Degree in nursing required. Master’s degree in nursing or related healthcare field required.
California RN licensure required.

Five years of direct experience in an acute care setting.
Five years of demonstrated progressive management experience with increasing scope of responsibility with the last two years at a Director level.
Previous experience in leading Patient Safety with a focus on High Reliability and Zero Harm.
Previous experience working with Medical Staff Leadership.
Strong knowledge of accreditation and regulatory requirements (The Joint Commission, National Committee on Quality Assurance, California Department of Public Health, Centers for Medicare and Medicaid)
Skills: Knowledge of statistical tools and analysis. Demonstrated initiative, follow through and ability to work independently.Demonstrated results oriented leadership style. Demonstrated effective project management skills. Excellent interpersonal, judgment and problem solving skills Excellent written and verbal communication and presentation skills. Knowledge of and experience with organizational change processes.

Must be able to deal with job-related stress, multiple projects and deadlines.

Basic computer skills.

EHR experience.

Interpersonal Skills:

Demonstrates the NorthBay Way.The NorthBay Way is a set of value-based behaviors that are to be consistently demonstrated and role modeled by all employees that work at NorthBay Healthcare. The NorthBay Way principles consist of Caring, Communication, Collaboration, and Competence.

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NorthBay Healthcare

Fairfield, CA

Job Type: Employee

Job Status: Full Time

EOE / Drug Free Workplace