Director of Quality Improvement and Patient Safety - LECOM Health

Director of Quality Improvement and Patient Safety

Millcreek Community Hospital


Plans, implements and manages quality assessment, performance improvement and patient safety programs designed to monitor and enhance the quality of patient care in cooperation with all hospital departments.

Collaborates with hospital and physician leaders to envision, develop, and implement the organization’s quality and patient safety plans.



  1. Maintain established hospital/departmental policies, procedures, objectives, safety, environmental and infection control standards.
  2. Coordinate and oversee hospital Quality Improvement Plan development, review, revision, and implementation
  3. Plan, organize and direct departmental quality improvement projects and activities.
  4. Plan and implement quality assessment/performance improvement program to meet the needs of the hospital, focusing on patient care initiatives.
  5. Evaluate programs and effect changes as needed to support the hospital’s objectives and goals and to assure compliance with regulatory requirements.
  6. Review data related to clinical care, report appropriate information at committee assignments and to regulatory programs, and follow-up as necessary.
  7. Maintain close liaison with all hospital departments to assure coordination, standardization and continuity of quality and performance improvement programs and participate in the compliance of quality programs, such as Quality Blue.
  8. Coordinate and manage Core Measures and other value based purchasing reporting and other functions.
  9. Collect and report HCAHPS data for the facility functions.
  10. Coordinate concurrent review studies and peer review activities performed within the Quality assessment/performance improvement program and disseminate this information appropriately.
  11. Oversee regulatory readiness with regards to PA Department of Health inspections, Healthcare Facilities Accreditation Program (HFAP), and other accreditors/regulators visits making sure that all departments and staff are in compliance with all rules, regulations and policies governing the hospital.
  12. Develop, evaluate, and maintain quality dashboards and performance metrics.
  13. Manage patient complaint and grievance .
    1. Manage an effective complaint/grievance reporting system.
    2. Conduct investigations of complaints/grievances.
    3. Prepare and distribute monthly, quarterly and annual reports to appropriate departments and committees.
    4. Promote a culture of safety, high-reliability, patient and staff engagement, and performance excellence.
  14. Execute the Patient Safety Program in accordance with PA Act 13.
    1. Coordinate and prioritize the activities of the patient safety committee.
    2. Develop and implement adequate internal information and management systems and utilize information from external sources to support the activities of the patient safety program.
    3. Oversee and coordinate the investigation of serious events and as appropriate, identify incidents.
    4. Ensure compliance with sentinel event, serious event, incident, and infrastructure failure reporting requirements as mandated by the law/regulations or to meet accreditation standards.
    5. Ensure the disclosure of serious events to patients and/or families is carried out in accordance with organizational policy and law/regulations.
    6. Devise strategies to enlist medical staff, employee, and patient family input into the organization’s patient safety program.
    7. Support and encourage error reporting throughout the organization through a non-punitive error reporting approach.
    8. Recommend and facilitate change within the organization to improve patient safety based on identified risks and proactive risk mitigation.
  15. Establish and maintain tracking systems to ensure positive changes for current and future initiatives. Facilitate corrective action plan development and monitor progress to completion.
  16. Must be a team player and be able to communicate and interact with all staff including physicians also with patients/families as necessary.
  17. Attend meetings and participate on committees as required.
  18. Keep administration informed of department activities, needs and problems.
  19. Perform other duties as assigned or requested.


Minimum Education:  Bachelor Degree in a related field or certification/licensure with experience in quality management with technical knowledge of the administrative, operational and clinical healthcare functions including: quality and process improvement, regulatory/compliance, clinical quality data management, and patient safety required in a health related field.

Preferred Education:  Master’s degree with experience having coordinated, prepared and participated in state, Joint Commission/HFAP and/or CMS survey within the past 3 years

Minimum Experience: Must have two years of leadership experience.