Job Description

Quality and safety aren’t just metrics at Logan Health Medical Center. They’re the foundation of everything we do. We’re looking for a senior leader who sees it the same way and is ready to own that mission at the executive level.

The Executive Director of Quality, Patient Safety, and Patient Experience leads one of the most visible and impactful portfolios at LHMC, setting the strategic direction for how we protect patients, improve outcomes, and deliver care experiences that our community can trust. Reporting to the Chief Medical Officer, this leader works in close partnership with physician quality leadership, medical staff, and senior leaders across the organization to drive high-reliability practices, reduce preventable harm, and ensure regulatory and accreditation excellence.

This is a role for someone who doesn’t just manage programs but builds the systems, culture, and accountability that make lasting change possible. If you bring deep expertise across quality, patient safety, and patient experience, and you know how to translate data into action and alignment across a complex organization, we’d love to talk.

At Logan Health, our leaders are empowered to make meaningful impact, supporting both frontline caregivers and the patients and communities we serve.

Our Mission Quality, compassionate care for all.

Our Vision Reimagine health care through connection, service and innovation.

Our Core Values Be Kind | Trust and Be Trusted | Work Together | Strive for Excellence.

What Success Looks Like

Success in this role includes:

• Measurable reductions in adverse events and preventable harm across LHMC

• Improved patient experience scores and meaningful progress in person- and family-centered care

• Sustained accreditation readiness and successful regulatory survey outcomes

• A strong, engaged team culture where staff feel supported, developed, and accountable

• Data-driven decision-making embedded across clinical and operational leadership

• Recognition as a trusted strategic advisor by executive leadership and the Board

Leadership Competencies

The successful candidate will demonstrate:

• Deep expertise across quality, patient safety, and patient experience as distinct healthcare specialties

• Emotional intelligence, professionalism, and executive leadership presence

• Exceptional relationship-building, negotiation, and consensus-building capabilities

• Ability to lead through influence and build alignment across clinical, operational, and administrative stakeholders

• Business acumen including fiscal management, budgeting, and resource stewardship

Key Responsibilities

Quality, Safety & Patient Experience Strategy

• Set the strategic direction and oversee the development, implementation, and delivery of clinical quality, patient safety, and patient experience programs across LHMC

• Develop and steward the annual QAPI plan, embedding continuous improvement across clinical and operational environments

• Establish and monitor key performance indicators, dashboards, scorecards, and benchmarking tools to drive improvement

• Champion patient experience, advancing person- and family-centered care and integrating patient-reported outcomes

• Direct quality measurement, analytics, and performance reporting to internal and external stakeholders

• Use patient feedback, analytics, and equity data to drive improvement; lead initiatives related to grievances, complaints, and service recovery

Patient Safety, Infection Prevention & Emergency Preparedness

• Lead and oversee patient safety event reporting, root cause analysis, corrective action planning, and proactive risk-mitigation initiatives

• Oversee patient safety event review processes, including presentation of system-level recommendations to the Senior Executive Team and relevant Board Committees

• Oversee drug diversion, medication safety, and clinical safety programs

• Oversee infection prevention and control programs to reduce healthcare-associated infections and ensure compliance with evidence-based protocols

• Oversee emergency preparedness planning and programs, ensuring organizational readiness and compliance with regulatory requirements

Accreditation, Regulatory & Compliance

• Ensure readiness and compliance with CMS Conditions of Participation, DNV accreditation standards, and all applicable state and federal requirements

• Interpret and operationalize regulations from CMS, FDA, OCR, OIG, state agencies, and accrediting bodies

• Direct compliance programs, audits, surveys, and corrective action plans

• Monitor regulatory and legislative changes, assess organizational impact, and advise proactive responses

Team Development & Organizational Stewardship

• Develop, mentor, and inspire staff across the quality, safety, and patient experience portfolio in a culture of continuous improvement and collaboration

• Provide subject matter expertise and education to clinical leadership, medical staff, and partners regarding quality, patient safety, regulations, and emerging best practices

• Develop and manage operating and capital budgets aligned with strategic priorities

• Represent LHMC on relevant organizational, system, and national committees; chair quality and patient safety councils as required

Required Qualifications

• Bachelor’s degree in Healthcare Administration, Nursing, or a related field required

• Master’s degree in Healthcare Administration, Nursing, Business Administration (MBA), or a related field strongly preferred

• Minimum of eight (8) years of progressive leadership experience in quality, patient safety, or a closely related healthcare specialty

• Demonstrated expertise in quality improvement methodologies, patient safety science, and regulatory standards

• Demonstrated proficiency with both inpatient and ambulatory quality initiatives

• Experience leading regulatory audits, surveys, or investigations (CMS, DNV, state agencies)

• Experience leading enterprise-level patient safety, quality, and patient experience initiatives

• Demonstrated knowledge of healthcare operations, regulatory requirements, accreditation standards, and care delivery systems

• Professional certification preferred but not required (CPHQ, CPPS, CPXP, or CPHRM)

Shift:

Day Shift - Variable Hours (United States of America)

Schedule:

Logan Health operates 24 hours per day, seven days per week. Schedules are set to accommodate the requirements of the position and the needs of the organization and may be adjusted as needed.

Notice of Pre-Employment Screening Requirements

If you receive a job offer, please note all offers are contingent upon passing a pre-employment screening, which includes:

• Criminal background check

• Reference checks

• Drug Screening

• Health and Immunizations Screening

• Physical Demand Review/Screening

Equal Opportunity Employer

Logan Health is an Equal Opportunity Employer (EOE/AA/M-F/Vet/Disability). We encourage all qualified individuals to apply for employment. We do not discriminate against any applicant or employee based on protected veteran status, race, color, gender, sexual orientation, religion, national origin, age, disability or any other basis protected by applicable law. If you require accommodation to complete the application, testing or interview process, please notify Human Resources.