Director of Quality – Women’s and Children Services

A Brief Overview

The Director of Quality, Safety, Accreditation and Policy provides strategic and operational leadership for clinical

quality, patient safety, regulatory readiness, accreditation compliance, and organizational policy management

across a large, complex medical center. The Director establishes priorities, ensures alignment across clinical and

operational functions, and partners with physician, nursing, operational, and administrative executives to

advance high reliability, continuous improvement, regulatory excellence, and patient-centered care. This position

has accountability for the design, execution, and sustained performance of quality improvement, patient safety,

accreditation, policy governance, performance measurement, and regulatory compliance programs. The Director

translates organizational strategy into medical center-wide priorities, evaluates performance and risk, directs

corrective action, and provides executive leaders with recommendations needed to achieve organizational goals

and external standards.

What You Will Do

• Quality and Performance Improvement
• Establish and lead the organization's quality, safety, accreditation, and policy strategy in alignment with

organizational strategy and medical center priorities.

• Set the performance improvement agenda and direct organization-wide and departmental initiatives,

including prioritization, resource allocation, accountability, and sustainability of results.

• Establish performance expectations and governance for key quality indicators, publicly reported

measures, regulatory metrics, and improvement commitments; intervene when performance or

compliance is at risk.

• Facilitate data-driven improvement efforts using Lean, Six Sigma, PDSA, and other improvement

methodologies.

• Own the integrity, interpretation, and executive communication of quality dashboards, scorecards, and

performance reporting, including recommendations for action and escalation.

• Partner with physician and nursing leaders to improve clinical outcomes, reliability, equity, and patient

experience.

• Exercise decision-making authority within the assigned portfolio and escalate material quality, safety,

regulatory, or accreditation risks to executive leadership and appropriate governance bodies.

• Define accountability structures for leaders responsible for performance improvement plans and verify

that corrective actions produce sustained results.

• Patient Safety
• Provide leadership for the patient safety program and establish expectations for a culture of safety, high

reliability, transparency, learning, and accountability

• Direct governance for event reporting, root cause analyses, apparent cause analyses, and corrective

action plans; ensure timely escalation, leadership accountability, and validation that risk-reduction

actions are effective and sustained.

• In partnership with Risk and clinical loss control, monitor serious safety events, near misses, and highreliability

metrics.

• Collaborate with risk management, infection prevention, and operational leaders on safety priorities.
• Integrate patient safety, infection prevention, clinical risk, quality improvement, and regulatory priorities

to reduce duplication, close gaps, and promote consistent practices across care settings.

• Support implementation of evidence-based practices to reduce preventable harm.
• Accreditation and Regulatory Compliance
• Provide oversight of Joint Commission, DNV, CMS, state, and specialty accreditation readiness,

partnering with the designated accreditation leader who directs day-to-day readiness activities to include

establishing priorities, assigning corrective actions, and escalating unresolved compliance risks.

• Oversee organizational responses to survey findings and regulatory deficiencies, including corrective

action governance, evidence submission, validation of sustained compliance, and executive escalation;

monitor regulatory changes and communicate implications to leadership; and partner with operational

leaders to address gaps and sustain compliance.

• Policy Management and Governance
• Lead policy governance and document control processes including standards for development, approval,

publication, review, exception management, and retirement.

• Ensure policies remain current, evidence-based, and aligned with regulatory requirements.
• Coordinate policy review cycles and approvals with clinical, operational, legal, compliance, and executive

stakeholders.

Evaluate policy compliance trends and identify improvement opportunities.

• Resolve or escalate cross-functional policy conflicts and ensure accountable leaders address material

gaps in policy implementation or adherence.

• Maintain oversight of organizational policy standards and publication processes. Consistent with UH

policy governance structures, accreditation, compliance, legal, quality, and operational leaders

collaborate to ensure policy adherence and regulatory alignment.

• Academic Mission Support
• Collaborate with medical school leadership, residency and fellowship programs, and research leadership

to integrate quality, safety, and regulatory expectations into organizational programs.

• Support quality and safety education for medical students, residents, fellows, and faculty.
• Leadership and Operations
• Establish departmental goals, operating plans, budgets, staffing models, and resource priorities; monitor

financial and operational performance and adjust plans as organizational needs change.

• Build leadership capability and succession plans for quality, safety, accreditation, regulatory, policy, and

performance improvement professionals; hold direct reports accountable for measurable outcomes.

• Serve as the quality and safety advisor to executive, physician, nursing, and operational leadership,

providing independent evaluation of performance, risk, regulatory exposure, and improvement priorities.

• Present quality, safety, accreditation, regulatory, and policy performance to governing boards, executive

committees, and medical staff leadership; recommend decisions, investments, and corrective actions.

• Chair or lead multidisciplinary governance committees focused on quality, accreditation, safety,

regulatory compliance, and policy, with authority to establish agendas, assign accountability, and

escalate unresolved issues.

• Negotiate priorities and resource needs across competing operational demands while protecting

regulatory compliance, patient safety, and organizational performance.

• Represent the medical center in organization-wide councils and, as assigned, with external regulators,

accrediting organizations, professional associations, and community partners.

Additional Responsibilities

• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during

orientation.

• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for

our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to

address appropriate use of PHI in the workplace.

Education Qualifications

• Bachelor's Degree in Healthcare Administration, Nursing, Public Health, Business Administration, or

related field (Required)

• Master's Degree in Healthcare Administration, Nursing, Public Health, Business Administration, or related

field Preferred (Preferred)

Experience Qualifications

• 8+ years of experience in healthcare quality, patient safety, accreditation, regulatory, and clinical

leadership experience with several years in people management capacity[ (Required)

• Experience within an academic medical center, integrated delivery system, or large healthcare

organization. (Required)

• • Experience with Joint Commission/DNV survey leadership. • Experience overseeing policy governance.
• Experience leading multidisciplinary teams, influencing senior and executive leaders, managing

organizational change, and sustaining measurable results across complex operations. • Experience

presenting to governing boards, executive committees, medical staff leadership, or comparable senior

governance groups. • Experience managing budgets, staffing plans, and resource allocation for a

complex function or department. (Preferred

Licenses and Certifications

• • Certified Professional in Healthcare Quality (CPHQ) • Certified Professional in Patient Safety (CPPS) •

Lean Six Sigma Green Belt, Black Belt, or equivalent • Healthcare accreditation or regulatory certification

(Preferred)

Physical Demands

- Standing Occasionally - Walking Occasionally - Sitting Constantly - Lifting Rarely 20 lbs - Carrying Rarely 20 lbs - Pushing Rarely 20 lbs - Pulling Rarely 20 lbs - Climbing Rarely 20 lbs - Balancing Rarely - Stooping Rarely - Kneeling Rarely - Crouching Rarely - Crawling Rarely - Reaching Rarely - Handling Occasionally - Grasping Occasionally - Feeling Rarely - Talking Constantly - Hearing Constantly - Repetitive Motions Frequently - Eye/Hand/Foot Coordination Frequently

Travel Requirements

• 10%