Executive Director, Quality

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence, and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what’s possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry and in people’s lives. Job Summary The Executive Director of Quality and Safety is responsible for developing a vision and executable plan to attain world‑class quality and safety processes and procedures across the hospital and all hospital outpatient departments (HOD) and any associated Health Parks. Accountable for ensuring successful development and deployment of the WellStar Quality and Safety strategy in a manner that supports achievement of WellStar Quality goals. Bringing patient safety and clinical quality expertise, he or she will partner with leadership, staff, and system partners to identify opportunities for short and long‑term impact on quality and safety outcomes in alignment with WellStar's strategic plan. Plans, organizes, and directs all services and operations of the department, which includes quality performance improvement, continuous survey readiness, and infection prevention programs for the hospital. Works collaboratively with hospital Vice Presidents, Directors and Managers, as well as system leadership and peers to align department goals with Hospital and System strategic goals. Oversees daily operations to ensure delivery of high‑quality services and supports execution of tactics designed to meet the goals. Is responsible for coordinating activities of Quality Committees with appropriate personnel, including medical staff quality, PI and peer review committees. Ensures processes in support of accurate and high‑performing publicly reported quality data, WellStar quality goals and applicable data registries. Leads hospital implementation and ongoing support of Lean PI methodology. Serves as an influential champion for the WellStar Safety First program, supporting a fair and just culture of safety, accountability, and organizational learning. Works to effectively integrate functions and coordinate collaboration across the care continuum. Partners with external organizations to ensure regulatory and accreditation standards compliance and to infuse best practices into improvement efforts. The individual in this role will proactively identify opportunities to optimize performance, build internal competencies, foster a strong and empowered team, and create a rigorous approach to quality and safety throughout the organization, with a strong focus on the patient, accountability, and appropriate use of resources. Core Responsibilities and Essential Functions Establishes, Oversees, and Executes the Quality and Reliability Program, including Patient Safety: Provide centralized direction, governance and leadership for major projects and programs related to Quality Performance and Patient Safety. Develop and implement the long‑term and short‑term strategy for Safety and Quality. Ensure governance‑level Quality reports and communications support the Board of Trustees and delegated Board committees to meet fiduciary responsibilities. Meet all regulatory and accreditation requirements with respect to periodic quality and safety related reports. Serve as liaison to all local‑level business units and entities for oversight and advising on quality improvement projects and their alignment with system goals. Responsible for managing quality improvement and infection control for the hospital and associated Health Parks. Chair and participate in quality committees coordinated/facilitated by the department, including Quality Review Committee, Infection Control Committee, Value Committee, Medication Safety, and/or Peer Review Committees. Integrate other appropriate improvement and High Reliability strategies and tools. Provide advisory coaching and educational training on process improvement projects, methodology, tools, and standards. Mitigate medical/legal liability through development of a program which links risk management activities with those of continuous performance improvement. Contribute to the management of the accreditation, regulation, and licensing activities to include communicating the programs/processes to providers and medical staff, preparing surveys and inspections, and completing assessments, response plans and measures of success. Oversee and facilitate reliable safety event classifications and identification of Wellstar reportable safety events. Oversee safety event reporting and documentation in the electronic event reporting system, including identification of safety event trends and cause‑analysis processes, tracks, and trends progress. Oversee cause analysis training and root and apparent cause‑analysis processes for Wellstar reportable events; foster identification of reliable root causes, action plans, measures of success, and shared learning across the system. Contribute to the provision of high‑quality patient care by supporting infection prevention and control practices and compliance with regulatory agencies. Participate in the identification, prevention, and control of infections by performing surveillance activities, data collection, analysis, and reporting. Investigate infection control problems and infectious disease outbreaks. Identify responses to improve patient care systems and mitigate risk. Coordinate Quality and Patient Safety training, including simulation, periodic Environment of Care survey, and other events. Participate in annual mock accreditation survey and support Failure Mode and Effects Analyses for newly internalized services. Evaluate staff performance and development, develop, monitor, and control department budgets, make recommendations regarding the need for staff, space, and other resources, and perform other duties as assigned. Comply with all Wellstar Health System policies, standards of work, and code of conduct. Required Minimum Education Masters Public Health or Masters Health Administration or Masters Business Administration/Management or Masters Nursing or Masters Other Required Minimum License(s) and Certification(s) CPHQ – Certified Professional in Healthcare Quality Additional License(s) and Certification(s) RN Reg Nurse (Single State) – Preferred upon hire RN‑COMPACT – RN Multi‑State Compact – Preferred upon hire Required Minimum Experience Minimum five years of progressive experience in healthcare quality services or support. Minimum five years of experience managing a team directly, or minimum five years of experience with significant project or functional leadership within quality services. Previous experience with proven leadership in regulatory and accreditation survey readiness, quality improvement, and patient safety in a large acute care system or facility, including demonstrated ability to interpret quality metrics to lead actionable change. Strong experience with patient safety event management, including conducting root cause analysis and facilitating effective, timely action plans. Experience leading improvement work using a scientific methodology. Lean management system and Lean Production System methodology – preferred. Experience coordinating with and reporting data to a Patient Safety Organization (PSO) – preferred. Experience managing and/or monitoring infection prevention functions – preferred. Required Minimum Skills Strong interpersonal skills with the ability to communicate and work with all levels of healthcare providers, including physicians. Ability to perform duties and responsibilities promptly and consistently with little direct supervision. Ability to execute a plan and use project management methodology. Ability to plan and direct activities of others and provide feedback regarding outcomes or performance. Ability to work collaboratively with other departments within and outside the hospital. Ability to judge the appropriate action in response to changes, circumstances, or problems. Experience in data collection, analysis and project management. Strong computer skills. Excellent communication, presentation and organization skills. Working knowledge of data collection methodologies, interpretation/analysis, and decision support databases. Exposure to workflow in event management systems with the ability to interpret and utilize trended event data to improve safety. Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. Connect with the most integrated health system in Georgia and start a future that gives you more. #J-18808-Ljbffr