The Joint Commission

Associate Director, Office Quality & Patient Safety

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Provides leadership assistance to management of components of OQPS programs, policy and processes; implementation and maintenance of OQPS and relevant patient safety initiatives; as well as technical infrastructure and information technology development. Supports activities of the Office of Quality & Patient Safety, which includes  activities associated with the Joint Commission’s review and response to patient safety complaints and sentinel events and its activities surrounding the management and sharing of data and information regarding such events. Serves as a key Joint Commission contact who responds to internal and external inquiries related to the processes for patient safety complaints and sentinel event management, including organization responses, initiation of for-cause survey, and root cause analysis reviews. Acts in accordance with the Public Information Policy, the Sentinel Event Policy, Patient Safety Systems Chapter and other policies which guide OQPS patient safety complaints & sentinel event activities and supports the maintenance of the OQPS database warehouse. Assists in the management of multiple complex and confidential projects which meet the organizational priorities of the Joint Commission and serves as a department liaison in the conduct of multi-divisional activities and related external activities.




  • Assists OQPS Director to manage daily operations and performs delegated responsibilities as assigned.
  • Leads implementation for strategic initiatives of the department and division as needed.
  • Assists with recruits, hires, and performance evaluations of staff, as appropriate. Ensures that staff receives appropriate orientation and ongoing training. Provides supervision to Patient Safety Specialists and Safety Event Intake Coordinators serving as a mentor, coach and leader. Works with all staff to develop and attain their personal learning goals and performance expectations and to manage their workload within defined parameters.
  • Lead intra- and inter department improvement projects successfully and within expected timeframes.
  • Interpret OQPS data to provide appropriate context and to help identify organizational priorities.
  • Provides direction to patient safety specialists (PSS) on which policy, procedure, protocols to follow related to both complaint, sentinel event and for-cause survey process. 
  • Monitors timeliness of established turnaround responses for safety events, sentinel events and for-cause surveys based on OQPS department protocols and CMS guidelines.
  • Provides direction to the team on reviews of safety event organization responses and sentinel event comprehensive systematic analysis (RCA and other tools).
  • Evaluates OQPS survey approval process for Provides recommendations on the on-site survey approval.
  • Serves as a team member within the Accreditation Operations (ACO)/OQPS Core Team to facilitate collaborative development and implementation of for-cause survey standard workflow process. Ensures that an on-site survey occurs within the required timeframe; collaborates with ACO senior directors and field directors to accomplish.
  • Responds to internal and external inquiries regarding patient safety events, sentinel events and for cause surveys, in accordance with the Joint Commission’s Public Information Policy. This includes directly responding to requests from media, legal and other Joint Commission departments.
  • Directly responds to questions from accredited organizations related to sentinel event policy and patient safety questions submitted to SIGInquires.
  • Works with the OQPS Director and Medical Director to develop annual goals and budget for the Office of Quality & Patient Safety. Collaborates with the Director and Medical Director to implement, monitor and measure success.
  • Works with the Director and Medical Director to develop, obtain approval for, as appropriate, and administer policies and procedures relative to the operations of the Office of Quality & Patient Safety.
  • Serves as a key individual in presenting information about the Joint Commission’s patient safety event, sentinel event and for-cause survey processes to such audiences as CMS and other governmental agencies, licensing and certification agencies and peer review
  • Serves as a key subject matter expert to various Joint Commission departments, such as Communications, Customer Services, Federal Relations, and State Relations, relative to matters concerning the Office of Quality & Patient Safety.
  • Serves as a role model in the support of and implementation of enterprise, division and departmental missions and initiatives utilizing RPI tools and strategies. Leads and/or participates in internal work groups to identify and implement improvements to internal processes. Achieves, at a minimum, Yellow Belt certification, within one year of hire, and continues to pursue advanced RPI.
  • Provides educational offerings as requested for organizations and associations regarding analysis of patient safety events and sentinel events and learning from root cause analyses and aggregate event
  • Collaborates with the Director to develop and maintain a comprehensive safety nomenclature and categorization
  • Manages development, testing and implementation of Information Technology functionality for QMS, GSAP and RCA applications.
  • Collaborates with the Director and Medical Director to operationalize risk reduction hierarchy and safety procedures to assure requirements are met for safety analysis, documentation, and
  • Prepares and presents memoranda, analysis, and ad-hoc reports for senior management concerning all aspects of OQPS performance. This may include financial analysis and manpower projections needed to meet goals. Assists with the development of the departments’s annual budget, and monitors variances, revenue and expense forecasts, and conducts ad-hoc analysis.
  • Develops and executes enterprise-wide safety curricula and education
  • Works collaboratively with enterprise-wide management to develop patient safety improvement initiatives.










  1. A clinician , with minimum master’s degree, preferably in healthcare administration, public administration, nursing, policy or business.
  2. Five years of recent hospital clinical experience, with at least seven to ten years in a management role required.  Experience in Patient Safety as demonstrated by experience with adverse event management, safety data analytics, risk assessment/reduction strategy implementation and knowledge of patient safety science is required. Additional experience in quality improvement, risk management, accreditation/regulatory, project management or patient experience is desirable.
  3. Experience in data management, statistics, or LEAN/Six Sigma preferred.
  4. Knowledge of Joint Commission operations including the accreditation and certification decision methodology, the Standards Interpretation Group processes, and root cause analysis concepts.
  5. Demonstrated ability to deal with sensitive issues and various audiences; direct experience dealing with the public
  6. Demonstrated excellent customer relationship management skills, strong operational, presentation, analytical, and interpersonal skills.
  1. Demonstrated ability to function well in a fast-paced and challenging environment.
  1. Experience in managing diverse multi-disciplinary teams.
  2. Strong computer skills required, including familiarity with databases, graphics and word processing.


This job description is intended to describe the general nature and level of work performed by an employee assigned to this position. The description is not an exhaustive list of all duties, responsibilities, knowledge, skills and abilities, and working conditions associated with this position. All requirements are subject to possible modification due to business needs and/or reasonable accommodations for individuals with disabilities.


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