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Greater Peoria, IL
Greater Peoria, IL

Director, Quality, Safety and Risk- CMH Compliance



Legal, Quality Assurance
Peoria, IL, USA
Posted on Friday, September 1, 2023

Job Description

The Director of Safety & Quality serves as a highly visible champion of quality and safety throughout the region. This role works closely with the Chief Medical Officer and Chief Nursing Officer to provide leadership for system-wide efforts to continuously improve the quality and safety of care. This position leads the organization to achieve outstanding performance on key nationally standardized metrics of quality and safety. This position directs, plans and implements the Performance Improvement Plan, the Safety Plan, Accreditation efforts and Clinical Data Management. This position plans, organizes and directs the department/staff responsible for patient safety, environment of care safety, data collection and presentation, and regulatory compliance

  • Master's Degree in the field of Nursing, Healthcare Administration or Business Administration
  • 5-7 years of experience in/with prior experience which demonstrates clinical and leadership competence. It is imperative that the person have an excellent understanding of current trends and issues in the professional practices of multiple disciplines. Successful performance of the position’s accountabilities requires effective leadership skills, ability to prioritize multiple demands, and in-depth patient care knowledge.
  • Outstanding listening, interpersonal relationship building, and problem-solving skills
  • Exceptional level of professionalism, discretion and the ability to work on highly sensitive and confidential projects
  • Able to prioritize and manage multiple projects simultaneously with demonstrated ability to complete projects successfully on time and within budget
  • Knowledge of current trends and best practices in healthcare quality improvement and patient safety
  • Highly developed skills using personal computer tools including MS Office



  • Develops the organizational PI plan and the steps to implement the plan across the organization to assure a systematic, consistent approach to PI across the continuum. The plan supports organizational strategies/objectives and PI initiatives are based upon the service line needs.
  • Develop and implement strategies to integrate plan and indicators within the organization, ensures effectiveness of the plan implementation, educates the organization on the plan and indicators as appropriate.
  • Facilitates reporting of performance improvement activity through a variety of channels including Leadership Team, Clinical Council, Medical Staff Departments/Committees, etc. Evaluates indicators in appropriate steering committees, departments, councils, etc.
  • Works with all Service Lines and departments as they plan, develop and implement PI projects in their areas. Ensures collaboration and integration of all key customers.
  • Serves as educator, facilitator, and internal consultant to the Board, Executive team, Quality Council, Medical Staff, clinical implementation teams and departments throughout MHSC.
  • Maintains current understanding of the healthcare environment, including regulatory reporting environment, pay for performance, community measurement, accountable care organizations, and quality reporting.


  • Collaborate with clinical staff to develop, implement, monitor and champion performance improvement processes and policies related to key patient safety issues.
  • Coordinate efforts of various departments/stakeholders related to patient safety, share the experience/learnings with others through professional presentations, publications, etc.
  • Oversees the collection and dispersion of information related to patient safety through monitoring and reporting performance relative to patient safety indicators.
  • Oversees organizational Patient Safety Initiatives including thorough and credible root cause analysis which lead to organizational learning.
  • Oversees the development and implementation of plans to position the hospital as a leader in patient safety.
  • Fosters a culture within Methodist that promotes prevention, detection, and resolution of conduct that does not conform to established standards, regulatory requirements, and Methodist ethical and business policies.