Description

The System Quality and Safety Director for the Children and Women’s ICCE reports to the System QAPI Director and works collaboratively with the Leadership of the Children and Women’s (CHW) ICCE at MUSC. Under limited supervision, the Director provides full support to the QAPI/safety program system wide, collecting relevant quality data, analyzing and assessing data, working with relevant stakeholders on disseminating data and information, benchmarking performance, and leading multidisciplinary teams to improve outcomes. This position collects and presents performance data to relevant oversight and governance groups. This position leads and oversees all QAPI and regulatory/accreditation activities for the ICCE. The Quality/Safety Director also monitors and collates patient safety events in collaboration with the operational and clinical leaders and works with the Risk management department to facilitate event reviews and appropriate after review actions. The Quality and Safety Director is responsible for managing a team, either directly or indirectly, to include associated Quality and Safety Officers, managers, coordinators, data analysts, and registry staff. The CHW Director will be responsible for establishing subspecialty QAPIs across all pediatric specialties. The Director also advances leadership development, workforce growth, and education on patient safety and quality initiatives.

Key Responsibilities
The Quality and Safety Director - Children’s and Women’s reports to the System QAPI Director and works collaboratively with the Leadership of the Children and Women’s (CHW) ICCE at MUSC. Under limited supervision, the Director provides full support to the QAPI/safety program system wide, collecting relevant quality data, analyzing and assessing data, working with relevant stakeholders on disseminating data and information, benchmarking performance, and leading multidisciplinary teams to improve outcomes.

This position leads and oversees all QAPI and regulatory/accreditation activities for the ICCE. The Quality and Safety Director is responsible for managing a team, either directly or indirectly, to include associated Quality and Safety Officers, managers, coordinators, data analysts, and registry staff. The Director also advances leadership development, workforce growth, and education on patient safety and quality initiatives.

Strategic Planning for Children and Women’s ICCE QAPIs — 5%:
-Lead the development of a comprehensive 3–5-year QAPI strategic roadmap, in partnership with Quality and Safety Officers, hospital quality leadership, and ICCE stakeholders, inclusive of financial planning, defined outcomes, and measurable return on investment.
-Establish and prioritize annual strategic objectives and enterprise-level implementation plans that align with system quality strategy and regulatory expectations.
-Ensure disciplined execution of the QAPI strategic plan through defined milestones, performance metrics, and accountability structures; proactively identify risks and mitigation strategies to sustain progress.
-Provide regular executive-level updates on strategic performance, alignment, and impact to senior leadership and governing bodies.

Improve Culture of Safety and Decrease Harm by Implementing the Organization’s Safety Program in Collaboration with the System Safety Officer —25%
-Collaborate with established hospital committees and various ICCE leadership to implement improvements in patient safety.
-Facilitate the development of patient safety coaches.
-Provide guidance for clinical and non-clinical units to implement safety strategies to prevent hospital acquired complications such as infections, falls, medication and lab errors, sepsis, failure to rescue pressure injury and healthcare acquired infections. Lead apparent cause analyses as appropriate.
-Oversee the operation and implementation of all quality- and safety-related IMPROVE projects related to Children’s and Women’s Care and ensure enduring change.
-Work with Quality and Safety Officers to coordinate Safety Rounds and HAC Huddles as directed to improve the culture of safety system wide.
-Analyze Culture of Safety data and implement action plans.
-Partner with system leadership to plan and implement activities for Patient Safety Week.
-Monitor compliance with National Patient Safety Goals and lead teams to improve any deficiencies.
-Coordinate and implement all safety-related reward and recognition activities.

Provide Leadership and Oversight for All Aspects of the CHW-Related QAPI Programs — 40%
-Establish and govern a comprehensive Children’s QAPI framework that is fully operational, data driven, and aligned with system strategy and regulatory requirements.
-Supervise and support the Women’s QAPI Program and all associated FTE’s.
-Serve as the enterprise leader for quality measurement within assigned ICCEs, overseeing the integration and interpretation of internal and external data sources (e.g., Vizient, PHIS, CMS, U.S. News, Epic, Tableau).
-Provide strategic oversight of publicly reported, regulatory, and registry-based performance measures, ensuring accuracy, validation, and proactive performance management.
-Provide guidance and oversight of Children’s Surgical Verification (CSV) Program and associated FTEs.
-Lead the prioritization, governance, and accountability structure for Quality-related IMPROVE initiatives across the care continuum.
-Partner with senior and ICCE leadership to define annual quality priorities, performance indicators, benchmarks, and improvement strategies, ensuring alignment with enterprise objectives and regulatory bodies.
-Translate performance data into executive-level insights and action plans; prepare and present high-level outcome and performance reports to senior leadership committees and governing bodies.
-Ensure KPIs across the ICCE are systematically reviewed within the QAPI structure and drive measurable improvement in quality, safety, and patient outcomes.
-Advance enterprise quality strategy by embedding health equity principles into performance monitoring and improvement initiatives.
-Provide executive oversight of safety event review processes in collaboration with Risk Management and ICCE leadership, ensuring systemic learning and sustainable improvement. Champion a culture of safety, accountability, and continuous improvement through leadership engagement and targeted education initiatives.
-Develop, Implement, and/or participate in any relevant quality and safety education and training sessions for care team members across the system.

Coordinate the Collection, Documentation, and Distribution of ICCE Quality and Safety Data to and from Requests, Registries, Insurance Companies/Payers, Leaders, Team Members, and Governance Groups — 5%
-Establish and oversee a standardized data governance framework ensuring accuracy, timeliness, regulatory compliance, and transparency of all ICCE quality reporting.
-Lead the development of standardized, executive-level outcome and performance reports across programs.
-Provide oversight of registry, payer, and external reporting requirements to ensure readiness and submission accuracy.
-Partner with clinical, operational, and analytics leaders to strengthen data infrastructure, increase availability of discrete quality data, and align reporting with QAPI priorities.
-Oversee clinical data abstraction processes (as applicable) to ensure alignment with regulatory standards and performance improvement goals.
-Collaborate across system quality, regulatory, analytics, and affiliated entities (e.g., MUHA, MCP, Health Alliance) to ensure coordinated enterprise reporting.

Lead Improvement Efforts in All ICCE Specific Regulatory and Accreditation Programs — 10%
-Oversee regulatory and accreditation requirements for ICCE specific regulatory and accreditation programs.
-Perform gap analyses to determine needs for anticipated future accreditation programs.
-Serve as a subject matter expert on ICCE specific regulatory and accreditation program rules/regulations.
-Based on the strategic plan manage and oversee new certifications or new regulatory or accreditation requirements.
-Coordinate the development of the QAPI structure and reporting requirements to meet the standards per the appropriate regulatory body.
-In collaboration with MUSC Leadership, review, update, and implement all CHW quality-related policies and procedures.
-Ensure compliance with MUSC-approved policies and procedures.
-Prepare all documents required for regulatory and accreditation visits in collaboration with the hospital regulatory and accreditation department.
-Maintain current knowledge of requirements related to the appropriate regulatory bodies within the ICCE specific regulatory and accreditation program.
-Collaborate with clinical and operations leaders to make certain proper data and metrics are
kept up to date and accurate prior to submission deadlines.
-Collaborate with clinical and operational leaders to audit and observe clinic workflows to ensure compliance with Accreditation Standards.

Manage the Day-to-Day Operation and Performance of the Children’s and Women’s Quality and Safety Team and Any Associated Direct Reports — 15%
-Oversee operations and performance of Quality/Safety teams, including but not limited to officers, managers, coordinators, analysts, and/or registry personnel.
-Training and development of any direct reports.
-Implement analytics tools to support strategy and performance improvement.
-Ensure alignment of projects with ICCE and system-wide goals.

Requirements

The successful candidate will bring demonstrated experience working in a healthcare organization quality/safety program, along with the technical knowledge and operational judgment required to lead quality, safety, regulatory, accreditation, and education initiatives across the Children and Women’s ICCE.

Qualifications and Preferred Experience:  
-Computer/internet skills and familiarity with MS Office products (Word, Excel, PowerPoint, Access, etc.) essential.
-Experience with LEAN/Six Sigma and certification in Six Sigma preferred.
-Experience with Just Culture required; certification preferred.
-Experience with Epic EMR preferred.
-Experience within the Pediatrics Inpatient field is strongly preferred.
-Ability to travel, as needed, to various sites across the state to meet with key stakeholders related to the quality and safety program.

Minimum Requirements:  

-Graduation from an accredited graduate program with a healthcare related master’s degree required with at least 5 years’ experience in working in a healthcare organization quality/safety program.
-Certification as Certified Professional in Healthcare Quality or Patient Safety; preferred.
-Computer/internet skills and familiarity with MS Office products (Word, Excel, PowerPoint, Access, etc.); essential.
-Experience with LEAN/Six Sigma and certification in Six Sigma; preferred.
-Experience with Just Culture required, certification preferred.
-Experience with Epic EMR; preferred.
-Experience within the Pediatrics Inpatient field; strongly preferred