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Start the day excited to make a difference...end the day knowing you did. Come join our team.
Job Summary:
The Quality and Patient Safety Manager is responsible for overseeing the quality and safety initiatives within the organization by leading a team focused on patient safety, quality improvement, and regulatory compliance. This role ensures the team adheres to clinical guidelines, implements evidence-based practices, and drives continuous improvements in patient care. The Manager collaborates with clinical teams and leadership to monitor, evaluate, and optimize patient safety and quality outcomes, while also managing staff development, performance, and training.
Essential Functions & Responsibilities Team Leadership & Department Management
Manage a team of quality and patient safety Associates, providing leadership, guidance, and support to ensure optimal team performance and professional growth. Supervise team members by conducting regular performance evaluations, providing constructive feedback, and identifying opportunities for career development and skill-building. Oversee recruitment, hiring, and onboarding of new team members, ensuring a smooth integration into the department and alignment with organizational goals. Foster a positive team culture focused on collaboration, accountability, and a commitment to patient safety and quality improvement. Assist leadership in developing and maintaining departmental budget; establishes and assures adherence to budgets.
Quality & Patient Safety Program Oversight
Lead the implementation and monitoring of quality and patient safety programs, ensuring adherence to clinical guidelines, protocols, and regulatory standards. Ensure compliance with key safety and quality measures, monitoring performance metrics and outcomes to identify areas for improvement. Collaborate with interdisciplinary teams, including physicians, nurses, and leadership, to ensure that patient safety initiatives are effectively executed. Oversee daily operations of quality and safety activities, ensuring processes are efficient and aligned with best practices.
Education & Training
Develop and manage training programs for staff on patient safety and quality improvement topics, ensuring they are current and aligned with regulatory updates and evidence-based practices. Provide ongoing education to clinical and support staff through workshops, in-services, and just-in-time training, with a focus on quality standards, documentation, and safety protocols. Lead orientation and onboarding sessions for new team members to ensure consistency in quality and safety practices across the department.
Data Analysis & Reporting
Oversee the collection, analysis, and reporting of quality and patient safety data, ensuring the accuracy and timeliness of all submissions. Track quality metrics and safety outcomes, identifying trends and areas for improvement. Prepare reports for internal stakeholders and regulatory bodies, summarizing performance data and identifying actionable insights to enhance patient care.
Quality Improvement & Continuous Improvement
Lead quality improvement initiatives aimed at improving patient safety and clinical outcomes, with a focus on reducing complications and optimizing care delivery. Facilitate root cause analyses for patient safety incidents and quality care gaps, and implement corrective actions as needed. Develop and implement action plans to address performance gaps and promote continuous improvement across departments.
Regulatory & Compliance Management
Ensure compliance with regulatory standards (e.g., Joint Commission, CMS) and accreditation requirements related to patient safety and quality. Prepare for audits and reviews by ensuring the department is meeting regulatory and safety standards. Assist in preparing documentation and data for regulatory bodies, ensuring timely and accurate submissions.
Collaboration & Stakeholder Engagement
Collaborate with clinical leadership and department heads to align patient safety and quality objectives with organizational goals. Lead or participate in interdisciplinary meetings, working to address quality issues, review patient safety concerns, and implement solutions. Promote a culture of safety and quality, encouraging staff engagement and accountability for patient safety across the organization.
Qualifications Required
Valid RN License from Virginia or a reciprocal compact state. Minimum of 5 years of clinical experience, with at least 2 years in a leadership or management role focused on quality, patient safety, or clinical care. Strong leadership and interpersonal skills, with the ability to manage, motivate, and develop staff. Excellent communication skills, both verbal and written, with the ability to interact effectively with various stakeholders. Proficiency with EPIC and Microsoft Office Suite. Ability to prioritize, manage time effectively, and oversee multiple projects and initiatives simultaneously.
Preferred
Bachelor's Degree in Nursing or related field. Experience in quality improvement, patient safety, or clinical care settings. Certification in Quality and Patient Safety (e.g., CPHQ - Certified Professional in Healthcare Quality). Experience with process improvement methodologies (e.g., Lean, Six Sigma). Experience in designing and delivering educational programs for clinical staff.
As an EOE/AA employer, the organization will not discriminate in its employment practices due to an applicant's race, color, religion, sex, sexual orientation, gender identity, national origin, and veteran or disability status.
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Mary Washington Healthcare
Nov 11, 2025