About this role
When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.
Job Description:
Beth Israel Deaconess Hospital-Plymouth recognizes Integrity, Respect, Trust, Teamwork and Excellence as the Core Values of our organization. It is the philosophy of BID-Plymouth to follow the LEAN methodology in order to provide the full continuum of health care services and the best quality patient centered care.
Position Summary:
Reporting to the Chief Medical Officer, the Director of Quality, Risk and Patient Experience provides strategic and operational leadership for quality improvement, patient safety, risk management, regulatory compliance, patient experience, infection prevention, quality analytics, and interpreter services at Beth Israel Deaconess Hospital-Plymouth (BIDP).
Working collaboratively with clinical, operational, and administrative leaders, the Director advances the hospital's Quality and Safety Plan by leading initiatives that improve clinical outcomes, patient safety, service excellence, regulatory performance, and operational effectiveness. This role promotes a culture of continuous improvement, innovation, accountability, and patient-centered care through the application of LEAN principles and evidence-based quality methodologies.
The Director serves as a key advisor to hospital leadership and partners closely with Beth Israel Lahey Health (BILH) quality and patient safety leadership to implement systemwide priorities, achieve organizational performance goals, and ensure regulatory readiness.
This is an on-site leadership position requiring regular rounding throughout the organization and engagement with clinical and operational teams.
Duties/Responsibilities:
Quality, Safety, and Performance Improvement
- Provide strategic and operational leadership for Quality Improvement, Quality Analytics, Patient Experience, Risk Management, Infection Prevention, and Interpreter Services.
- Lead the development, implementation, monitoring, and evaluation of quality, patient safety, and performance improvement initiatives.
- Utilize LEAN, Six Sigma, change management, and project management methodologies to improve clinical outcomes, patient experience, operational performance, and patient safety.
- Monitor organizational performance through quality metrics, benchmarking data, and public reporting programs, including BILH quality goals.
- Promote a culture of patient safety, continuous improvement, accountability, and Just Culture principles.
- Support the collection, analysis, and interpretation of quality and patient safety data to identify trends, opportunities, and corrective actions.
- Facilitate communication, knowledge sharing, and best-practice adoption across clinical and operational leadership teams.
Regulatory and Accreditation Oversight
- Direct organization-wide readiness efforts for surveys conducted by The Joint Commission, CMS, the Massachusetts Department of Public Health, and other regulatory or accrediting bodies.
- Oversee compliance programs and continuous regulatory readiness activities to ensure adherence to applicable standards and requirements.
- Partner with administrative and clinical leaders to embed regulatory preparedness into daily operations and clinical practice.
- Develop and implement education and training programs related to regulatory, quality, and patient safety requirements.
Risk Management and Peer Review
- Provide executive oversight of the hospital's Risk Management program, including event reporting, safety investigations, claims support, corrective action planning, and organizational learning.
- Lead collaborative case reviews and other risk mitigation activities following significant events.
- Collaborate with legal counsel, medical staff leadership, and operational leaders to proactively identify and mitigate organizational risks.
- Support the medical peer review process and coordinate required reporting to regulatory agencies.
Infection Prevention
- Oversee the Infection Prevention and Control Program and ensure compliance with regulatory, accreditation, and evidence-based practice standards.
- Partner with clinical leaders to reduce healthcare-associated infections and improve patient safety outcomes.
Patient Experience and Service Excellence
- Lead the organization's patient experience strategy, including patient satisfaction, service excellence initiatives, patient relations, complaint and grievance management, and patient-centered care improvement efforts.
- Collaborate with operational and clinical leaders to improve communication, access, engagement, and patient experience outcomes.
- Promote initiatives that enhance service excellence and strengthen organizational culture.
Interpreter Services and Health Equity
- Oversee Interpreter Services and ensure compliance with federal, state, and accreditation requirements related to language access.
- Promote equitable communication and culturally responsive care throughout the organization.
Leadership and Administration
- Serve as a strategic advisor to executive and clinical leadership on quality, safety, risk, patient experience, and regulatory matters.
- Establish and maintain productive relationships within Beth Israel Lahey Health and external organizations, including professional and regulatory agencies.
- Develop departmental goals, monitor performance, manage budgets, and support staff development.
- Remain current with emerging healthcare quality, patient safety, risk management, and regulatory trends.
- Perform other duties as assigned.
Education/Experience:
Required
- Bachelor's degree in Nursing, Healthcare Administration, Public Health, Health Sciences, or a related healthcare field.
- Current Massachusetts Registered Nurse (RN) license.
- Five to ten years of progressive leadership experience in healthcare quality, patient safety, risk management, regulatory affairs, accreditation, or performance improvement.
- Demonstrated experience leading regulatory readiness activities, quality improvement programs, patient safety initiatives, risk management functions, and multidisciplinary performance improvement efforts.
- Exceptional communication, relationship management, presentation, and change leadership skills.
- Other clinical credentials (MD, DO, NP, PA, PharmD) will be considered but are not required.
Preferred
- Master's degree in Nursing, Healthcare Administration, Public Health, Business Administration, Healthcare Quality, or a related field.
- Certified Professional in Healthcare Quality (CPHQ) certification at hire, or obtained within 12 months of employment.
- Lean Healthcare, Lean, Six Sigma Green Belt, or Six Sigma Black Belt certification.
- Certification in Just Culture, Patient Safety, Risk Management, or a related discipline.
Physical/Environmental Requirements
This job requires frequent bending, carrying, pulling, pushing, reaching, standing, stooping, walking and lifting over 10 lbs. There will be occasional need for climbing stairs, lifting in excess of 50 – 100 lbs and sitting. Constant use of hearing, sight and speech. Frequent use of smell and touch. Frequent keyboard and telephone use. Constant concentration and problem solving.
Schedule : Full-time, 40 hours per week M-F on-site required
Pay Range:
$155,002.00 USD - $226,595.00 USD
The pay range listed for this position is the annual base salary range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law.