Strategic oversight and support for the hospitals patient safety program. Advise top management on strategies for improving culture of safety. Apparent, root cause analysis, tool & behavior training & support; evaluation of program effectiveness, data; coordinate with system wide PS director to assure integration of corporate initiatives. Facilitates the organization-wide quality improvement activities, assure continuous readiness & compliance with health care accrediting standards, compliance with CMS Core Measures, PFP, MU quality data and Q-HIP programs. Coordinate quality and PI initiatives, including oversight of the reporting and tracking system to ensure ongoing quality and performance. Oversight of the IPC department; development & monitoring of processes to ensure compliance with regulatory requirements which enhance the quality and safety of care. Provide oversight for OPPE & peer review activities to ensure quality of care is achieved and maintained. Report to top management performance of the QMS program. Ensure corrective & preventive actions reviewed/sustained; ensure conformance to ISO standards & hospital processes; annual evaluation; coordinates hospital DNV/ISO surveys and required follow up; ensures internal audit process compliance.Bachelor's degree and two (2) years relevant experience may be considered in lieu of master's degree. Change Management experience required. Event Prevention Philosophies experience required. Knowledge of human error and event prevention required. Project Management experience required. Occasional travel required.