Director Quality Management

St. Luke’s University Health Network; Allentown (Lehigh County); On-site; USD 120,000 - 180,000; Full time

Job summary

St. Luke's University Health Network is seeking a Director of Quality and Patient Safety to oversee quality, clinical risk management and patient safety across the assigned entity.

The role will coordinate performance improvement activities, facilitate process and system changes to enhance patient safety, and collaborate with network partners to improve care across the continuum. The position requires a nursing or healthcare-related bachelor’s degree, with a master’s preferred and professional

Qualifications

• Bachelor’s degree in nursing or healthcare related field is required.
• Master’s degree preferred or in progress with an identified completion date.
• CPHQ or CPHRM certification or appropriate equivalent within 2 years of hire.

Responsibilities

• Facilitates quality and patient safety goals established by Leadership.
• Assists in identifying benchmarks and opportunities for improvement.
• Guides efforts toward attaining top decile performance and outcomes.
• Investigates actual and potential adverse clinical events at assigned entity via the Patient Safety Hotline.
• Analyzes actual and potential adverse clinical events at assigned entity for risk prevention and mitigation using root cause analysis.
• Coordinates licensure surveys and complaint investigations.
• Facilitates/leads organizational improvement activities utilizing the PDCA methodology.
• Provides education, consultative services and/or technical assistance to Practice leaders and committees.
• Collaborates with physicians, administrators and service lines to meet performance improvement requirements.
• Works with Decision Support to determine performance metrics.

Skills

Quality improvement

Clinical risk management

Data analysis

Project management

Education

Bachelor’s degree in nursing or healthcare related field

Master’s degree preferred

CPHQ/CPHRM certification within 2 years

Tools

PDCA methodology

Regulatory compliance

Job description

St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.

The Director, Quality and Patient Safety is responsible for all aspects of Quality, Clinical Risk Management and Patient Safety for their assigned entity. This individual will coordinate performance improvement activities, facilitate process and/or system changes to enhance patient safety, and collaborate with the network partners to enhance the delivery of quality and safe patient care across the continuum.

JOB DUTIES AND RESPONSIBILITIES:

• Facilitates quality and patient safety goals established by Leadership
• assists in identifying benchmarks and opportunities for improvement
• guides efforts towards attaining top decile performance and outcomes
• Promptly investigates actual and potential adverse clinical events at assigned entity, including those reported via the Patient Safety Hotline.
• Analyzes actual and potential adverse clinical events at assigned entity for risk prevention and mitigation initiatives utilizing root cause/intense analysis process.
• Coordinates implementation of Patient Complaint and Grievance process at assigned entity.
• Reviews patient complaints and grievances and offers recommendations to effectively mitigate organizational risk.
• Oversees entity Infection Control Preventionist at assigned entity, directly and/or in a matrix reporting model with the Network Manager of Infection Control and Prevention
• Collaborates with Network Standards and Accreditation to assure compliance with regulatory and accrediting organizations
• NJ based position is responsible for NJ regulatory compliance for hospital and other NJ DOH licensed locations.
• Coordinates licensure surveys and complaint investigations.
• Facilitates/leads organizational improvement activities utilizing the PDCA methodology.
• Recommends tools and assists teams throughout the improvement process.
• Provides education, consultative services and/or technical assistance to Practice leaders, Performance Improvement Committees, Service line improvement teams and others.
• Conducts concurrent review of the literature and websites to provide teams and Service Lines with up-to‑date evidence and best practice recommendations.
• Works in a collaborative manner with physicians, administrators, practice managers and others to identify and meet the continuous performance improvement requirements of the organization.
• Collaborates with Decision Support staff to determine performance metrics for key process and performance improvement initiatives.
• Analyzes data reports and implements process to achieve improved performance.
• Additional duties and responsibilities as assigned

PHYSICAL AND SENSORY REQUIREMENTS:

• Sitting for up to 7 hours per day, 2 hours at a time.
• Frequently uses fingers for typing, data entry, etc.
• Frequent use of hands.
• Extensively uses mouse as a computer entry device.
• Uses upper extremities to lift up to 10 pounds.
• Rarely stoops, bends, or reaches above shoulder level.
• Hearing as it relates to normal conversation.
• Seeing as it relates to general vision, peripheral vision and near vision.

EDUCATION:

• Bachelor’s degree in nursing or healthcare related field is required.
• Master’s Degree preferred or in progress with an identified completion date within 4 years.
• Certified Professional in Healthcare Quality (CPHQ) or Certified Professional in Healthcare Risk Management (CPHRM) or appropriate alternative within 2 years of hire required.

TRAINING AND EXPERIENCE:

• Minimum of 3-5 years' experience in clinical care of patients required.
• Experience preparing comprehensive written reports and making effective training/education presentation.
• Excellent project management skills.
• Current professional licensure in New Jersey or Pennsylvania, based on work location.

Thank you for your interest in St. Luke's!!

St. Luke's University Health Network is an Equal Opportunity Employer.

Founded in 1872, St. Luke’s University Health Network (SLUHN) is a fully integrated, regional, non-profit network of more than 23,000 employees providing services at 16 campuses and 350+ outpatient sites. With annual net revenue in excess of $4 billion, the Network’s service area includes 11 counties in two states: Lehigh, Northampton, Berks, Bucks, Carbon, Montgomery, Monroe, Schuylkill and Luzerne counties in Pennsylvania and Warren and Hunterdon counties in New Jersey. St. Luke’s hospitals operate the largest network of trauma centers in Pennsylvania, with the Bethlehem Campus being home to St. Luke’s Children’s Hospital. SLUHN is the only Lehigh Valley-based health care system to earn Medicare’s five-star ratings (the highest) for quality, efficiency and patient satisfaction. It is both a Leapfrog Group and Healthgrades Top Hospital and a Newsweek World’s Best Hospital. The Network’s flagship University Hospital has earned the 100 Top Major Teaching Hospital designation from Premier 13 times total and eleven years in a row, including in 2023 when it was identified as THE #4 TEACHING HOSPITAL IN THE COUNTRY. In 2021, St. Luke’s was identified as one of the 15 Top Health Systems nationally. St. Luke’s is the ONLY health care institution in the Lehigh Valley to be named a Top Workplace regionally repeating the exclusive honor for the third year in a row. Also, for the third straight year, St. Luke’s has been a Top Workplaces in the Philadelphia Region by the Philadelphia Inquirer, ranking 9th in the large employer category for 2025 and the only health care system in PA to receive this award. In 2025, St. Luke’s was recognized as a national Top Workplaces by USA Today, three years in a row, including the 3rd best health care system in the nation in 2023 and 2024. Lastly, in 2025, St. Luke’s was named a Top Workplace in New Jersey for the third year in a row. Learn More Here.