Director, Patient Safety & High Reliability

Job description

SUMMARY:
The Director, Patient Safety & High Reliability provides strategic and operational leadership for the health system's patient safety, safety culture, and high reliability initiatives. This position develops, implements, and continuously improves a comprehensive enterprise patient safety program that advances High Reliability Organization principles, Just Culture, learning systems, proactive risk reduction, and harm prevention strategies.
The Director serves as a transformational leader and trusted advisor to executive leadership, medical staff, nursing leaders, and operational teams. This leader promotes transparency, accountability, continuous learning, workforce engagement, and measurable reduction of preventable patient harm while advancing the organization's journey toward highly reliable care.
ESSENTIAL FUNCTIONS:
STRATEGIC LEADERSHIP:
• Provide enterprise leadership for patient safety, high reliability, and harm reduction initiatives.
• Develop and implement a systemwide patient safety strategic plan aligned with organizational priorities.
• Serve as the operational leader for the organization's High Reliability journey.
• Advise leaders regarding emerging safety risks, mitigation strategies, and organizational learning priorities.

HIGH RELIABILITY ORGANIZATION LEADERSHIP:
• Lead deployment and sustainment of High Reliability principles across care settings.
• Develop and oversee HRO education, coaching, leadership development, and error-prevention practices.
• Integrate reliability behaviors, human factors principles, and systems thinking into daily operations.
• Partner with leaders to hardwire reliable practices and reinforce accountability for safe care.

PATIENT SAFETY PROGRAM MANAGEMENT:
• Develop, direct, and evaluate the comprehensive patient safety program.
• Establish annual safety priorities, performance goals, and measurable outcomes.
• Lead deployment of required Culture of Safety survey, results dissemination, and action plans for improvement.
• Oversee patient safety event reporting systems and organizational learning platforms.
• Ensure adverse events, near misses, and unsafe conditions are identified, reviewed, analyzed, and addressed.

EVENT INVESTIGATION AND ORGANIZATIONAL LEARNING:
• Oversee Apparent Cause Analyses, Cause Analysis and Action reviews as indicated, safety debriefs, hot washes, and learning reviews.
• Ensure corrective actions are specific, measurable, implemented, monitored, and sustained.
• Establish processes to spread lessons learned across the health system.
• Use systems-based methods to identify vulnerabilities and strengthen barriers and controls.

SAFETY CULTURE AND JUST CULTURE:
• Lead safety culture assessment, interpretation, action planning, and monitoring.
• Promote psychological safety, speaking-up behaviors, transparency, and respectful accountability.
• Support consistent application of Just Culture principles.
• Partner with leaders to improve workforce engagement in patient safety.

PERFORMANCE IMPROVEMENT AND HARM REDUCTION:
• Use safety data and analytics to identify trends, opportunities, and emerging risks.
• Collaborate with operational leaders to evaluate high-risk processes and implement mitigation strategies.
• Support evidence-based practices and multidisciplinary improvement initiatives.
• Lead enterprise initiatives focused on high-risk clinical areas and priority harm categories.

GOVERNANCE AND REPORTING:
• Facilitate both the Patient Safety and High Reliability Steering Committees.
• Provide regular reports to the Board Quality Committee, Patient Safety Committee, executive leadership, medical executive committees, and quality councils.
• Develop and maintain patient safety dashboards, harm measures, and high reliability implementation indicators.
• Communicate significant trends, events, corrective-action status, and strategic recommendations.
• Support effective board oversight of quality and patient safety.
• Facilitate site-specific Patient Safety Committee.

REGULATORY AND ACCREDITATION SUPPORT:
• Collaborate with clinical risk, regulatory, and accreditation leaders to support compliance with applicable patient safety standards.
• Support survey readiness and response planning for patient-safety-related findings, audits, or reviews.
• Adheres to TMCH organizational and department-specific safety, confidentiality, values, policies, and standards.
• Performs related duties as assigned.

MINIMUM QUALIFICATIONS
EDUCATION:
• Master's degree in Nursing, Healthcare Administration, Public Health, Quality, Patient Safety, or a related healthcare field required.

EXPERIENCE:
• Five (5) years of progressive healthcare quality, patient safety, risk, or clinical leadership experience required.
• Three (3) years of leadership experience managing teams, programs, or departments required.
• Experience leading a hospital or health system patient safety program preferred.
• Demonstrated experience with High Reliability principles, event investigation, and enterprise change preferred.

LICENSURE OR CERTIFICATION:
• Certified Professional in Patient Safety (CPPS) required within twelve (12) months of hire.
• Certified Professional in Healthcare Quality (CPHQ) required within twelve (12) months of hire.
• Certified Professional in Healthcare Risk Management (CPHRM) preferred.
• Just Culture certification and Lean Six Sigma Green Belt or higher preferred.

KNOWLEDGE, SKILLS AND ABILITIES:
• Advanced knowledge of patient safety science, High Reliability Organizations, human factors, Just Culture, systems thinking, event analysis, and harm reduction.
• Ability to lead complex, cross-functional initiatives and influence without direct authority.
• Strong executive communication, facilitation, change leadership, and conflict-resolution skills.
• Ability to interpret safety data, identify meaningful trends, and translate findings into action.
• Ability to manage sensitive and confidential information with sound judgment and professionalism.
• Ability to work effectively in a fast-paced environment and communicate with boards, executives, physicians, leaders, staff, patients, and external agencies.