Position Summary
The Director of Quality Assurance, Clinical Risk & Patient Safety serves as the operational leader for the organization's quality assurance, patient safety, clinical risk management, and FTCA risk management programs. Reporting to the Vice President of Quality and Compliance, the Director is responsible for developing, implementing, and continuously improving systems that promote safe, effective, patient-centered care while supporting regulatory readiness, organizational resilience, and continuous quality improvement.
The Director provides strategic and operational oversight for quality assurance activities, patient safety event reviews, root cause analyses, peer review processes, clinical risk assessments, performance improvement initiatives, and FTCA risk management requirements. The position collaborates closely with clinical, operational, and executive leaders to identify opportunities for improvement, implement corrective actions, reduce clinical risk, and strengthen patient outcomes.
As a key member of the Quality and Compliance leadership team, the Director serves as the organization's subject matter expert for patient safety, clinical quality, and clinical risk management. The Director partners closely with the Compliance & Enterprise Risk Manager and other organizational leaders to support a culture of safety, accountability, transparency, continuous improvement, and regulatory readiness.
Reportability
This position will report directly to the Vice President of Quality and Compliance.
This position will collaborate extensively with clinical, operational, medical, dental, behavioral health, nursing, compliance, quality, human resources, finance, information technology, legal, and executive leadership teams.
This position may supervise Quality Assurance, Risk Management, Patient Safety, Clinical Quality, or other support staff as organizational structure evolves.
Essential Duties and Responsibilities
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.
- Lead and maintain the organization's quality assurance, patient safety, clinical risk management, and FTCA risk management programs.
- Develop and implement strategies that improve clinical quality, patient outcomes, patient experience, and organizational safety culture.
- Direct patient safety activities, including incident reporting, event reviews, adverse event analysis, near-miss reporting, and identification of opportunities to prevent harm.
- Lead investigations of patient safety events, adverse clinical outcomes, grievances involving quality of care concerns, and potential professional liability exposures.
- Facilitate Root Cause Analyses (RCA), Failure Mode and Effects Analyses (FMEA), and other structured improvement methodologies to identify contributing factors and reduce future risk.
- Develop, monitor, and evaluate corrective and preventive action plans resulting from patient safety events, quality reviews, peer review activities, audits, inspections, and regulatory findings.
- Conduct clinical risk assessments and partner with leadership to identify, evaluate, mitigate, and monitor clinical and patient safety risks.
- Lead and coordinate FTCA risk management activities, including implementation of FTCA risk management requirements, annual assessments, documentation, and corrective action plans.
- Partner with medical, dental, behavioral health, nursing, and operational leaders to support Quality Assurance and Performance Improvement (QAPI) initiatives and organizational quality goals.
- Oversee clinical quality assurance processes, including evaluation of clinical performance, quality indicators, evidence-based practices, and opportunities for improvement.
- Coordinate and support peer review activities, professional practice evaluations, and clinical performance improvement processes in collaboration with medical leadership.
- Analyze quality, safety, clinical, and operational data to identify trends, emerging risks, performance gaps, and opportunities for improvement.
- Develop and maintain quality dashboards, scorecards, performance reports, and patient safety metrics for leadership and organizational committees.
- Lead or facilitate the organization’s Continuous Quality Improvement (CQI) Committee and ensure appropriate follow-up of recommendations and action items.
- Coordinate organizational readiness related to clinical quality, patient safety, FTCA deeming activities, HRSA Operational Site Visits (OSVs), accreditation reviews, payer audits, and other regulatory assessments.
- Collaborate with department leaders to develop and maintain clinical policies, procedures, protocols, and internal controls that promote quality, patient safety, risk reduction, and regulatory compliance.
- Provide subject matter expertise and support for clinical investigations involving patient safety, quality of care, FTCA, and other clinical risk concerns.
- Collaborate with the Compliance & Enterprise Risk Manager on investigations, audit, risk assessments, and corrective action plans involving both clinical risk and regulatory compliance considerations.
- Develop and deliver education and training related to quality improvement, patient safety, clinical risk management, event reporting, FTCA requirements, and high-reliability principles.
- Prepare quality, patient safety, FTCA, and clinical risk reports for leadership, executive management, and organizational committees.
- Serve as a liaison with insurers, legal counsel, external reviewers, regulatory agencies, consultants, and accrediting organizations regarding patient safety and clinical risk management matters.
- Foster a culture of safety, accountability, transparency, learning, and continuous improvement throughout the organization.
- Perform other duties as assigned.
Qualifications
The requirements listed below are representative of the knowledge, skills, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Knowledge, Skills & Abilities –
- Bachelor's degree in Nursing, Social Work, Public Health, Healthcare Administration, or a related field required; Master's degree preferred.
- Current, unrestricted RN or LCSW license required.
- Minimum three (3) years of experience leading Quality Assurance and Performance Improvement (QAPI), patient safety, clinical risk management, or related quality initiatives in a healthcare setting required.
- Knowledge of quality improvement, patient safety, peer review, clinical risk management, FTCA, HRSA, CMS, and accreditation requirements.
- Experience conducting root cause analyses, patient safety investigations, and corrective action planning.
- Strong leadership, analytical, communication, and relationship-building skills.
- Professional certification in healthcare quality, patient safety, or risk management preferred.
Language Requirement –
- No language requirement: Ability to communicate effectively in English is required. Additional language proficiency or fluency preferred.
Physical Demands – Regularly required to sit; frequently required to reach with hands and arms, walk, stoop, kneel, crouch, talk or hear; must be able to lift objects up to twenty-five (25) pounds.
Work Environment – Mostly in a typical office or clinic setting with quiet to moderate noise level. May be exposed to extreme cold, heat, and humidity due to outside weather conditions.
- Opportunity to work a hybrid schedule – remotely & onsite, as needed.
Benefits:
- Competitive benefits package, including medical, dental & vision insurance, plus retirement options
- 25 days of paid time off (PTO) annually, in addition to 10 paid holidays, plus educational days to attend training and conferences
- License renewals, if applicable
- $2000/year educational reimbursement to attend training and conferences
- NHSC/HRSA loan repayment options, if applicable
- WMATA metro/bus subsidy