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Job ID


Req. No


Job Title

Director, Patient Safety, Accreditation, and Quality


CHRISTUS St. Vincent






Not Defined


490A West Zia Rd
Santa Fe, NM  87505
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Full Time

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The Director establishes and sustains organization-wide processes and systems to maintain compliance with The Joint Commission (TJC) and Center for Medicare and Medicaid Services (CMS) standards. The function works with senior Leadership and the Leadership team (directors and managers) to direct and manage interdisciplinary teams to achieve continuous readiness with regulatory compliance. The Director has the direct responsibility for assessing the organization's compliance status, educating to The Joint Commission and CMS requirements, meeting regulatory deadlines and chairing the Continuous Survey Readiness Committee. This individual develops the goals and objectives for accreditation readiness, patient safety and quality

In addition, the Director has responsibility for coordinating and overseeing the development of comprehensive patient safety improvement initiatives to reduce medical errors and healthcare incidents and s/he leads the hospital's efforts related to promoting a just culture. The Director works collaboratively with executives, administrators, doctors, and nursing to develop effective strategies that boost patient safety. The Director advises risk, and guides clinical leaders, medical staff, operational leadership, and associates in a continual pursuit of patient safety improvement opportunities and promotes and vigorously supports a comprehensive culture of patient safety throughout the organization. The Director has primary oversight of the patient safety program under the direction of the regional PSO and collaborates with leadership to develop policies and procedures affecting organizational patient safety. The Director alerts leadership and the Quality Outcomes Committee to real or potential system-based causes of negative outcomes to patient safety.

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Director, Patient Safety, Accreditation, and Quality