Director, Patient Safety & Accreditation

Position Focus :

In 1971, Yale University established Yale Health to provide health services to its faculty, staff and students through a multidisciplinary health maintenance organization located on campus. Yale Health has over 49,000 members including students, staff, faculty and their families who come from every state in the country and almost every country in the world.

Reporting to the Associate Chief Operations Officer (ACOO), the Director of Patient Safety and Accreditation Preparedness serves as the organization’s key resource, providing strategic guidance and expertise on all matters related to patient safety and accreditation readiness. This position is responsible for establishing and executing a strategy to ensure Yale Health achieves and sustains the highest standards of clinical safety and accreditation excellence. The Director will inform organizational strategy, drive system-wide initiatives, and lead transformative efforts that advance patient care, mitigate risk, and ensure compliance with all accreditation requirements (State, Federal and accreditation entities). This senior role requires exceptional expertise, strategic vision, and a proven ability to lead in a complex healthcare environment, making it instrumental in shaping the future of safety and quality at Yale Health.

Responsibilities include :

• Develops and implements a comprehensive strategic plan for patient safety and regulatory preparedness that aligns with the organization’s mission, vision, and values. Provides guidance and strategic direction to senior leadership on patient safety, risk mitigation, and accreditation readiness.
• Drives innovative approaches to safety and regulatory preparedness, leveraging best practices and industry trends to position Yale Health as a leader in patient safety and compliance. Develops, monitors, and evaluates organizational goals and metrics related to patient safety, regulatory readiness, and accreditation compliance.
• Champions a culture of safety and continuous improvement by designing and delivering education, training, and communication strategies that empower staff to prioritize safety and adhere to regulatory requirements.
• Serves as the key resource on accreditation standards, including Joint Commission requirements, and state or federal regulations. Leads organization-wide readiness efforts for accreditation surveys, regulatory inspections, and certification processes. Directs post-survey follow-up activities, including the development of corrective action plans and long-term sustainability measures.
• Provide oversight for infection prevention programs within an ambulatory care setting, ensuring compliance with regulatory standards, implementation of evidence-based practices, and forges relationships with peers.
• Establishes and oversees systems for incident reporting, tracking, and analysis, and ensures timely and effective responses to adverse events, including root cause analyses and corrective action plans.
• Leads and mentors a team of professionals engaged in regulatory readiness, patient safety initiatives, and performance improvement efforts, ensuring continuous professional development and effective team performance.
• Partners with clinical and operational leaders to identify risks, develop error reduction strategies, and implement evidence-based practices that enhance patient safety and regulatory compliance.
• Collaborates with information systems teams to enhance the collection, analysis, and reporting of clinical and operational safety data, leveraging technology to drive decision-making and performance improvements.
• Builds and maintains strong relationships with external agencies, accreditation bodies, and regulatory entities, serve as the primary liaison to ensure alignment and effective communication.
• Partners with the ACOO to develop and manage budgets, resource allocation, and organizational priorities related to patient safety and regulatory preparedness.

Dept / Section URL

Essential Duties

1. Develops and implements a comprehensive strategic plan for patient safety and regulatory preparedness that aligns with the organization’s mission, vision, and values. Provides expert guidance and strategic direction to senior leadership on all aspects of patient safety, risk mitigation, and accreditation readiness. 2. Drives innovative approaches to safety and regulatory preparedness, leveraging best practices and industry trends to position Yale Health as a leader in patient safety and compliance. Develops, monitors, and evaluates organizational goals and metrics related to patient safety, regulatory readiness, and accreditation compliance. 3. Champions a culture of safety and continuous improvement by designing and delivering education, training, and communication strategies that empower staff to prioritize safety and adhere to regulatory requirements. 4. Serves as the key resource on accreditation standards, including Joint Commission requirements, and state or federal regulations related to safety and quality accreditation. Leads organization-wide readiness efforts for accreditation surveys, regulatory inspections, and certification processes, ensuring successful outcomes and sustained compliance. Directs post-survey follow-up activities, including the development of corrective action plans and long-term sustainability measures for ongoing compliance. 5. Provide strategic oversight for infection prevention programs within an ambulatory care setting, ensuring compliance with regulatory standards, the implementation of evidence-based practices, and forges relationships with peers. 6. Establishes and oversees robust systems for incident reporting, tracking, and analysis, including the Patient Safety Evaluation System, and ensures timely and effective responses to adverse events, including root cause analyses and corrective action plans. 7. Leads and mentors a team of professionals engaged in regulatory readiness, patient safety initiatives, and performance improvement efforts, ensuring continuous professional development and effective team performance. 8. Partners with clinical and operational leaders to identify risks, develop error reduction strategies, and implement evidence-based practices that enhance patient safety and regulatory compliance. 9. Collaborates with information systems teams to enhance the collection, analysis, and reporting of clinical and operational safety data, leveraging technology to drive decision-making and performance improvements. 10. Builds and maintains strong relationships with external agencies, accreditation bodies, and regulatory entities, serving as the primary liaison to ensure alignment and effective communication. 11. Partners with the Associate Chief Operations Officer to develop and manage budgets, resource allocation, and organizational priorities related to patient safety and regulatory preparedness.

Required Education and Experience

Bachelor’s degree in nursing, public health or another health-related field. Ten years of experience in a healthcare environment, in operations or comparable field. Two years of progressive management and / or supervisory experience.

Required Skill / Ability 1 :

Knowledge of safety tools and techniques including adverse event investigation, root cause analysis, systems thinking, and accreditation readiness and preparedness.

Required Skill / Ability 2 :

Well-developed leadership, decision-making, planning, organizational and problem-resolution skills.

Required Skill / Ability 3 :

Demonstrated ability to manage people and organize effective task forces and project teams. Experience with broad multi-disciplinary teams.

Required Skill / Ability 4 :

Comprehensive knowledge of nursing care practices and standards.

Required Skill / Ability 5 :

Excellent written and oral communication skills.

Preferred Education, Experience and Skills :

Master’s level training in nursing, public health or another health-related field highly preferred. Experience with Epic or similar EHR

Preferred Licenses or Certifications :

RN licensure; Certification (within a year) in safety, or accreditation or performance improvement.

Drug Screen

Health Screening

Background Check Requirements

All candidates for employment will be subject to pre-employment background screening for this position, which may include motor vehicle, DOT certification, drug testing and credit checks based on the position description and job requirements. All offers are contingent upon the successful completion of the background check. For additional information on the background check requirements and process visit "Learn about background checks" under the Applicant Support Resources section of Careers on the It's Your Yale website.

Health Care Worker

This role is a healthcare worker position. Healthcare workers (HCW) are defined as university employees working a healthcare setting who have the potential for direct or indirect exposure to patients, human research subjects or infectious materials including body substance, contaminated medical supplies, devices and equipment, surfaces, or air. HCW have specific health requirements that must be met prior to starting work, including MMR vaccine or immunity, varicella (chickenpox) vaccine or immunity, TB screening, COVID vaccine according to University policy, hepatitis B vaccine or immunity, and annual flu vaccination.

Posting Disclaimer

The intent of this job description is to provide a representative summary of the essential functions that will be required of the position and should not be construed as a declaration of specific duties and responsibilities of the particular position. Employees will be assigned specific job-related duties through their hiring departments.