Director of Quality and Patient Safety

Job ID
Employment Type
Full Time
Quality Management
Hours / Pay Period
Methodist Hospital Sacramento
Standard Hours
Monday - Friday (8:00 AM - 5:00 PM)
Work Schedule
8 Hour


Established in 1973, Methodist Hospital is a full-service community hospital committed to providing excellence in health care for residents living in Sacramento's southern suburbs, including Laguna, Elk Grove, and Galt. For additional information about Methodist Hospital, please visit us at Methodist Hospital is part of Dignity Health- a 21-state network of 9,000 physicians, 59,000 employees, and more than 400 care centers, including hospitals, urgent and occupational care, imaging centers, home health, and primary care clinics. In the Sacramento area, Dignity Health operates Mercy General Hospital, Mercy Hospital of Folsom, Mercy San Juan Medical Center, Methodist Hospital, Sierra Nevada Memorial Hospital, Woodland Memorial Hospital, and Mercy Medical Group (a service of Dignity Health Medical Foundation). Dignity Health is committed to delivering compassionate, high-quality, affordable health care services with special attention to the poor and underserved.


Position Summary:


Responsible for the design, coordination, implementation and management of the Organization’s Performance Improvement (PI) and Patient Safety plans.  Identifies opportunities for improved patient care and outcomes and reductions in harm, with the implementation of evidence-based practices. Provides leadership in defining, implementing and integrating quality, safety, service and efficiency strategies into the plans, policies, and organizational processes that affect the organization’s operations and strategic direction.


Principle Duties and Accountabilities:

  • Establishes performance improvement goals annually with relevant stakeholders. Ensures the Performance Improvement and Patient Safety plans and the hospital-focused projects for the year are implemented and their effectiveness is evaluated annually. Develops and implements processes and formats which support data collection, aggregation, analysis, and action planning. Assures data is managed appropriately and disseminated to appropriate leadership staff. Provides leadership in developing quality improvement and patient safety training programs and coaches organizational /service lines and operational/support departments in quality improvement principles.
  • Oversees the events reporting process, root cause analyses, investigations and requests from the claims team (including management of subpoenas, Summons and Complaints, and coordination of legal documents related to hospital liability). Participates in system office initiatives and programs to mitigate risks in the facility which have been identified at other hospitals, resulting in reduced costs, adverse patient outcomes and ultimately safer patient practices and care.
  • Collaborates with the Medical Staff and Organizational Leadership to develop and enhance safe patient care while achieving optimal outcomes, including the organization’s peer review program and ongoing and focused practitioner evaluation.
  • Provides leadership and is responsible for accreditation and regulatory survey readiness. Oversees mock survey tracers to assess survey readiness. Provides education to staff and providers on regulatory compliance. Organizes required staff to develop responses to survey deficiencies and submits responses to the appropriate accreditation or regulatory agency.


Patient Safety Director of Quality Clinical Nursing Performance Improvement CQI CPHQ HCQM CPQPS Sacramento Nursing Leadership RN Risk Management


Minimum Qualifications:

  • Certified Professional in Healthcare Quality (CPHQ), or Healthcare Quality and Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment is required
  • Bachelor's degree in a healthcare-related field or five (5) years of related job or industry experience in lieu of degree
  • Minimum of five (5) years of progressive management responsibility in an acute care setting
  • Two (2) of which is related to managing an organization’s Quality Improvement Program
  • Minimum of two (2) years of , patient care experience or equivalent. Experience developing and implementing , service and operational process improvement initiatives, both small and large scale
  • Knowledge and expertise in specific performance improvement/CQI methodologies (e.g., Six Sigma, LEAN)
  • Current knowledge of accreditation and regulatory requirements for acute and ambulatory care services (e.g. state, federal, local regulations; Joint Commission, etc.)

Quality “risk management” “patient safety” “process improvement” compliance regulatory accreditation “hospital safety” “performance improvement” “care mgmt.” “care management” “organizational change” risk lean implemented executed rcs “root cause” “patient safety goals” “quality measures”


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