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Job Title: VP, Quality Patient Safety

Company: Good Samaritan Hospital

City/State: Suffern, NY

Category: Executive/Management

Department: Administrative Admin

Position: Full Time

Hours: 75.00

Shift: Days

Req #: 448

Job Details:

The VP of Quality and Safety is responsible for the Bon Secours Charity Health System Quality Management Program and the development and analysis of the plans and programs to support continuous quality improvement. This individual is responsible for defining project scope, developing protocols and instruments, collecting and reporting data, determining necessary process changes, guiding teams and departments to implement changes, and monitoring and documenting outcomes to ensure that quality programs meet or exceed guidelines or requirements, including value based purchasing performance and other pay for performance programs. This position participates in ensuring that the organization is well prepared for all regulatory and accreditation surveys and meets all regulatory agency reporting requirements, and works closely with the Chief Information Officer to choose quality metrics for and ensure compliance with meaningful use requirements. 


  • Directs the day to day operations of the Quality and Safety Management Department in conjunction with other department directors.
  • Directs, develops, evaluates and continuously improves the hospital-wide performance improvement program to ensure program effectiveness through data analysis and education of employees in conjunction with other department directors.
  • Ensures efficiency, effectiveness and accuracy of data collection, analysis and reporting to drive performance improvement processes, and presents data in easy to understand dashboards that clearly display trends so as to assist department and leadership decision making.
  •  Identifies and coordinates performance improvement activities across all departments and service lines of the organization and coaches department heads in metric choice and development, including dashboard development for ease of tracking performance and outcomes.
  •  Participates in the development of annual performance improvement plan for the organization in accordance with regulatory agency requirements and the organization’s strategic plan. 
  • Participates as a key member in the development of strategies to ensure meaningful use quality metrics are built into the employee health record, and that data collection is pristine and reported as required.
  • Instrumental in ensuring that employee health record development includes required elements to meet regulatory data collection.
  • Coordinates the development of multidisciplinary performance improvement teams charged with developing strategies with improving quality measures outlined in commercial pay for performance contracts, and serves as facilitator for these groups to ensure successful outcomes.
  • Supervises and coordinates activities for external database participation and reviews contractual and reporting activities for these databases.
  • Assesses the Bon Secours Charity Health System’s compliance with accreditation standards and continued survey readiness, and participates, coaches’ hospital leadership in survey preparation.
  • Develops and implements policies and procedures for assigned areas of the Quality and Safety Department.
  • Develops, implements and evaluates specified components of the Quality and Safety Department to ensure efficient utilization of resource.
  • Works with departmental directors in the reporting and screening of incidents and occurrences to determine the next appropriate level of reporting, follow up, documentation, course of action and tracking and trending.
  • Works in collaboration with subject matter experts and conducts root cause analysis, including formulating questions related to events.
  • Works with risk management and patient relations through case referral and collaborative case analysis.
  • Prepares department’s operating and capital budget in conjunction with the Senior Vice President, and assists with monitoring department’s budgets and expense.
  • Oversees the management of the human resources functions for department staff and ensures appropriate levels of staff recruitment, performance, training and education, competency and professional development.
  • Collaborates with information systems staff to maintain current systems and plans for existing system upgrades to enhance productivity and efficiency of the operating system.
  • Promotes and provides quality customer service, and proactively identifies and resolves customer issues that relate to quality and performance improvement activities.
  • Ensures all protocols, policies and procedures are in compliance with the Medical Center’s policies and procedures, collective bargaining agreements, CMS and all other applicable accrediting organizations and regulatory bodies. 


 Seven years of managerial experience, four of which were in performance improvement, including the development and implementation of quality improvement deliverables and corrective action planning in or for a hospital or health care agency. 

 Comprehensive knowledge of quality assurance functions as they relate to utilization, discharge planning, case management and medical care audits; comprehensive knowledge of the principles of health care administration; thorough knowledge of the regulatory and accreditation standards for hospitals and nursing homes and of the New York State Education Law governing licensure and registration requirements for health care practitioners; thorough knowledge of hospital routine, organization and functions; thorough knowledge of the development, coordination, and delivery of medical services; thorough knowledge of the principles and practices of administrative supervising and decision making; ability to monitor and conduct analysis of hospital operating procedures, identify problems and critical factors and develop methods for corrective action; ability to develop and maintain effective working relationships with physicians, hospital managers, and other health care professionals which is conducive to code and standards compliance in their areas of responsibility; ability to delegate responsibility effectively, ability to communicate effectively both orally and in writing; ability to organize, assemble, categorize and prepare data for reporting purposes; ability to plan and supervise the work of others; sound professional judgment; dependability; tact; discretion; integrity; resourcefulness; accuracy; initiative; physical condition commensurate with the requirements of the position. 


A Bachelor’s degree required, Master’s degree preferred 


If applicable, the individual performing this job may reasonably anticipate coming into contact with human blood and other potentially infectious materials. Individuals in this position are required to exercise universal precautions, use personal protective equipment and devices, and learn the policies concerning infection control.

About Us:

Good Samaritan Hospital

Good Samaritan Hospital in Suffern, NY, is a 286-bed hospital providing emergency, medical, surgical, obstetrical/gynecological and acute-care services to residents of Rockland and southern Orange counties in New York; and northern Bergen County, NJ. The hospital is home to a recognized cardiovascular program, comprehensive cancer-treatment services, the area’s leading Wound and Hyperbaric Institute and outstanding maternal/child services that includes a Children’s Diagnostic Center. Good Samaritan Hospital also provides social, psychiatric and substance-abuse services and its certified home-care agency supports residents of the Hudson Valley and beyond.

Due to a recent upgrade in our online applicant tracking system, anyone who has previously applied for a position with Good Samaritan Hospital will be required to reapply.

With this recent upgrade to our system, all previous applications are no longer accessible by the WMCHealth Recruitment Team. We apologize for the inconvenience, and we appreciate your understanding during our efforts to upgrade our systems to be able to provide a better candidate experience.