A Brief Overview
The Director of Quality, Safety, Accreditation and Policy provides strategic and operational leadership for clinical
quality, patient safety, regulatory readiness, accreditation compliance, and organizational policy management
across a large, complex medical center. The Director establishes priorities, ensures alignment across clinical and
operational functions, and partners with physician, nursing, operational, and administrative executives to
advance high reliability, continuous improvement, regulatory excellence, and patient-centered care. This position
has accountability for the design, execution, and sustained performance of quality improvement, patient safety,
accreditation, policy governance, performance measurement, and regulatory compliance programs. The Director
translates organizational strategy into medical center-wide priorities, evaluates performance and risk, directs
corrective action, and provides executive leaders with recommendations needed to achieve organizational goals
and external standards.
What You Will Do
* Quality and Performance Improvement
* Establish and lead the organization's quality, safety, accreditation, and policy strategy in alignment with
organizational strategy and medical center priorities.
* Set the performance improvement agenda and direct organization-wide and departmental initiatives,
including prioritization, resource allocation, accountability, and sustainability of results.
* Establish performance expectations and governance for key quality indicators, publicly reported
measures, regulatory metrics, and improvement commitments; intervene when performance or
compliance is at risk.
* Facilitate data-driven improvement efforts using Lean, Six Sigma, PDSA, and other improvement
methodologies.
* Own the integrity, interpretation, and executive communication of quality dashboards, scorecards, and
performance reporting, including recommendations for action and escalation.
* Partner with physician and nursing leaders to improve clinical outcomes, reliability, equity, and patient
experience.
* Exercise decision-making authority within the assigned portfolio and escalate material quality, safety,
regulatory, or accreditation risks to executive leadership and appropriate governance bodies.
* Define accountability structures for leaders responsible for performance improvement plans and verify
that corrective actions produce sustained results.
* Patient Safety
* Provide leadership for the patient safety program and establish expectations for a culture of safety, high
reliability, transparency, learning, and accountability
* Direct governance for event reporting, root cause analyses, apparent cause analyses, and corrective
action plans; ensure timely escalation, leadership accountability, and validation that risk-reduction
actions are effective and sustained.
* In partnership with Risk and clinical loss control, monitor serious safety events, near misses, and highreliability
metrics.
* Collaborate with risk management, infection prevention, and operational leaders on safety priorities.
* Integrate patient safety, infection prevention, clinical risk, quality improvement, and regulatory priorities
to reduce duplication, close gaps, and promote consistent practices across care settings.
* Support implementation of evidence-based practices to reduce preventable harm.
* Accreditation and Regulatory Compliance
* Provide oversight of Joint Commission, DNV, CMS, state, and specialty accreditation readiness,
partnering with the designated accreditation leader who directs day-to-day readiness activities to include
establishing priorities, assigning corrective actions, and escalating unresolved compliance risks.
* Oversee organizational responses to survey findings and regulatory deficiencies, including corrective
action governance, evidence submission, validation of sustained compliance, and executive escalation;
monitor regulatory changes and communicate implications to leadership; and partner with operational
leaders to address gaps and sustain compliance.
* Policy Management and Governance
* Lead policy governance and document control processes including standards for development, approval,
publication, review, exception management, and retirement.
* Ensure policies remain current, evidence-based, and aligned with regulatory requirements.
* Coordinate policy review cycles and approvals with clinical, operational, legal, compliance, and executive
stakeholders.
Evaluate policy compliance trends and identify improvement opportunities.
* Resolve or escalate cross-functional policy conflicts and ensure accountable leaders address material
gaps in policy implementation or adherence.
* Maintain oversight of organizational policy standards and publication processes. Consistent with UH
policy governance structures, accreditation, compliance, legal, quality, and operational leaders
collaborate to ensure policy adherence and regulatory alignment.
* Academic Mission Support
* Collaborate with medical school leadership, residency and fellowship programs, and research leadership
to integrate quality, safety, and regulatory expectations into organizational programs.
* Support quality and safety education for medical students, residents, fellows, and faculty.
* Leadership and Operations
* Establish departmental goals, operating plans, budgets, staffing models, and resource priorities; monitor
financial and operational performance and adjust plans as organizational needs change.
* Build leadership capability and succession plans for quality, safety, accreditation, regulatory, policy, and
performance improvement professionals; hold direct reports accountable for measurable outcomes.
* Serve as the quality and safety advisor to executive, physician, nursing, and operational leadership,
providing independent evaluation of performance, risk, regulatory exposure, and improvement priorities.
* Present quality, safety, accreditation, regulatory, and policy performance to governing boards, executive
committees, and medical staff leadership; recommend decisions, investments, and corrective actions.
* Chair or lead multidisciplinary governance committees focused on quality, accreditation, safety,
regulatory compliance, and policy, with authority to establish agendas, assign accountability, and
escalate unresolved issues.
* Negotiate priorities and resource needs across competing operational demands while protecting
regulatory compliance, patient safety, and organizational performance.
* Represent the medical center in organization-wide councils and, as assigned, with external regulators,
accrediting organizations, professional associations, and community partners.
Additional Responsibilities
* Performs other duties as assigned.
* Complies with all policies and standards.
* For specific duties and responsibilities, refer to documentation provided by the department during
orientation.
* Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for
our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to
address appropriate use of PHI in the workplace.
University Hospitals
Nov 06, 2026