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**Job Type:** Regular

**Time Type:** Full time

**Work Shift:** Day (United States of America)

**FLSA Status:** Exempt

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

Job Description:

Winchester Hospital is a 5x Magnet designated, Top Massachusetts recognized 223-bed regional hospital that is the leading provider of comprehensive health care services in the northwest suburban Boston area.

The Executive Director of Quality & Patient Safety is a nurse leader responsible for the following:

+ Oversees and directs activities of Healthcare Quality, Performance Improvement/Risk Management and Nursing Informatics.

+ Exemplifies Winchester Hospital’s values and Service Excellence standards. Commits to making every encounter with our patients, patients’ family, co-workers, physicians and other customers the best that it can be.

+ Complies with Winchester Hospital policies and the Code of Business Conduct. Takes responsibility for own safety as well as the safety of patients, patients’ family, co-workers, physicians and other customers.

+ Recommends goals for Healthcare Quality, Performance Improvement/and Risk Management, Nursing Informatics and Health Equity to Vice President and implements agreed upon goals.

+ Updates all Directors and Managers on activities occurring in Performance Improvement and Joint Commission and regulatory agencies. Keeps staff informed of all hospital events, initiatives etc.

+ Develops and oversees implementation of policies and procedures to support the Quality Assessment and Risk Management processes. Ensures compliance with all regulatory requirements as regards Quality Assessment such as Department of Health and Board of Registration Patient Care Assessment Regulations.

+ Oversees and leads the Joint Commission survey process.

+ Serves as a member of the Ethics Committee, Infection Control Committee, Cancer Committee, and Utilization Management Committee. Co-chairs the Health Equity Committee.

+ Serves as a risk consultant to physicians and staff on patient care issues. Handles sensitive patient care issues and complaints to minimize legal risks.

+ Trains staff on Quality Improvement process.

Qualifications:

+ Education/Licenses: Master’s degree in Nursing (or closely related field) or must obtain Master’s degree within 5 years of hire (either the Bachelors or Master’s degree must be in Nursing). Preferred: Master’s degree on hire

+ Required: Current license to practice professional nursing from the Massachusetts Board of Registration

+ Experience: At least five years of progressively more responsible experience in the health care field.

+ Professional Healthcare Quality (CPHQ) certification preferred.

Beth Israel Lahey Health (BILH) is an integrated health system dedicated to creating healthier communities — one person at a time — through seamless care and ground-breaking science, driven by excellence, innovation and equity.

Founded in 2019, our system brings together academic medical centers and teaching hospitals, community and specialty hospitals, primary and specialty care, behavioral health and home care services, and more than 5,900 physicians and 36,000 employees to care for more than 1.7 million patients in communities across Eastern Massachusetts and Southern New Hampshire. Together, we are changing healthcare for the better.

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more (https://www.bilh.org/newsroom/bilh-to-require-covid-19-influenza-vaccines-for-all-clinicians-staff-by-oct-31) about this requirement.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity** **Employer/Veterans/Disabled