Reporting directly to the Director of Quality & Patient Safety, fosters a culture of continuous improvement and coordinates the systematic implementation of effective practices designed to reduce errors and improve patient outcome. Manages the patient safety and accreditation/regulatory compliance programs. Functions as the patient safety advocate and mentor, interfacing with staff, leadership and patients. Collaborates and provides leadership to staff members’ daily efforts for identify and remove barriers for safe patient care delivery.

• Manages the facility Patient Safety Program including Patient Safety Plan and TJC requirements for the collection, analysis and reporting of events and patient safety data, investigation of events and near misses, and ensuring all accreditation and regulatory requirements for patient safety are fully met.
• Facilitates initiatives and programs to mitigate identified risks which result in reduced costs, reduced adverse patient outcomes and safer patient care.
• Create systems and processes to continually evaluate safety information. Monitor established safety results and compile and present reports to administrative leadership with executive summaries and recommendations for actions as needed.
• Facilitates teams as necessary to achieve performance improvement and high reliability within the organization.
• Educates staff in continuous quality improvement and patient safety concepts, processes, and tools as needed.
• Manages the collection, measurement and presentation of data required for monitoring plans of correction, Joint Commission National Patient Safety Goals (NPSG), and patient safety indicators.
• Leads the hospital accreditation survey process. Reviews accreditation and regulatory agencies survey findings and develops and manages action plans to address non-compliance.
• Performs ongoing reviews of regulations for state, federal and other regulatory agencies, and apprises management of changes.
• Leads the team in any Root Cause Analysis and Failure Mode Effect Analysis necessary, documents and report finding to the appropriate leaders, committees or external agencies.
• Provide ongoing report to the Patient Safety Committee on all open plans of correction items.
• Prepares directives, guidelines, information on various topics of patient safety and ongoing compliance for dissemination throughout the Organization.

• Bachelor’s Degree Required
• Master’s Degree Preferred
• RN preferred
• Certification CPPS, CPHRM, CPHQ preferred
• 5 years’ experience accreditation or 3-5 years’ experience in patient safety or risk management

CentraState Healthcare System, in partnership with Atlantic Health System, is a fully accredited, not-for-profit, community-based health system dedicated to providing comprehensive health services in central New Jersey. Beyond offering a wide range of advanced diagnostic and treatment options, CentraState is committed to being a valuable health partner, focusing on disease prevention, promoting healthy behaviors, and helping individuals of all ages live well.

Located in Freehold, CentraState includes a 284-bed acute-care hospital, a dynamic health and wellness campus, two award-winning senior living communities, a charitable foundation, and convenient satellite health pavilions. These pavilions offer primary care, specialty physician practices, and access to outpatient services such as lab work and physical therapy.

CentraState is proud to be among the less than two percent of hospitals nationwide to earn Magnet® designation for nursing excellence five times. Additionally, it has been recognized as a Great Place to Work-Certified™ Company by Great Place to Work® for four consecutive years.

Joining CentraState means becoming part of a pioneering healthcare facility committed to high-quality, patient-focused care. We invite you to make a difference in our community and advance your career with us. We support our employees with work/life balance initiatives, tuition assistance, career advancement opportunities, and more.

Discover why our employees love their jobs and being part of the CentraState family!

CentraState Health System offers a competitive and comprehensive Total Rewards package that supports the health, financial security, and well-being of all team members.

What We Offer:

• Medical, Dental, Vision, Prescription Coverage (30 hours per week or above for full-time and part-time team members)
• Life & AD&D Insurance
• Long-Term Disability (with options to supplement)
• 403(b) Retirement Plan with employer match
• 401(a) Retirement Plan with employer contribution
• PTO
• Tuition Reimbursement
• Well-Being Rewards
• Employee Assistance Program (EAP)
• Fertility Coverage, Healthy Pregnancy Program
• Flexible Spending & Commuter Accounts
• Pet, Home & Auto, Identity Theft and Legal Insurance
• Growth Opportunity and Workforce Development Initiatives
• Continuing Education / Onsite Training
• A warm, welcoming company culture based upon mutual respect and a collaborative goal of providing excellent patient care
• Concierge Services with Work & Family Benefits
• Magnet recognized healthcare facility

Compensation Range: $107,250 - $182,330 annually

The compensation above reflects the established range from CentraState Healthcare System (CSHS) for this position at the time the job was posted. CSHS considers many factors to determine compensation, including education, experience, skills, licenses, certification, and training.  As such, team member compensation may fall outside this range. 

Additionally, the compensation range reflects base salary and does not include extra shift rates or incentives tied to quality, productivity, etc., as applicable.

The benefits outlined also reflect CSHS’ policy at the time of posting.  Benefits as are made available to other similarly situated team members of CSHS, although participation is at all times in accordance with and subject to the eligibility and other provisions of such plans and programs. CSHS may modify its benefits plans or programs at any time.

CSHS is proud to comply with all pay equity and pay transparency laws.