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Requisition Number::  16201
Date:  Feb 19, 2021

Durham, NC, US, 27710

Personnel Area:  DUKE HOSPITAL

Duke University Hospital is consistently rated as one of the best in the United States and is known around the world for its outstanding care and groundbreaking research. Duke University Hospital has 957 inpatient beds and offers comprehensive diagnostic and therapeutic facilities, including a regional emergency/trauma center; a major surgery suite containing 51 operating rooms; an endo-surgery center; an Ambulatory Surgery Center with nine operating rooms and an extensive diagnostic and interventional radiology area. In fiscal year 2018, Duke University Hospital admitted 42,916 patients and had 1,085,740 outpatient visits in fiscal year 2017.


U.S News & World Report named Duke University Hospital #1 in North Carolina and #1 in the Raleigh-Durham area in 2018-19.


Duke University Hospital is ranked in the top 20 nationally for seven adult specialties, including cardiology and heart surgery, nephrology, ophthalmology, orthopedics, pulmonology, rheumatology, and urology.


In addition to its hospitals, Duke Health has an extensive, geographically dispersed network of outpatient facilities that include primary care offices, urgent care centers, multi-specialty clinics and outpatient surgery centers.


General Description of the Job Class:


The Executive Director of Patient Safety, will establish and direct a comprehensive and efficient Patient Safety program, ensuring compliance with existing regulations, standards, and internal and external policies and procedures. This leader is responsible for providing leadership in the development of a culture of safety, and provides services, which promote the physical and psychological safety of patients, visitors, and caregivers in an academic medical center. Services include risk assessment, plan development and implementation, safety and policy / procedure management, and proactive process improvement to prevent harm and improve quality of care outcomes.


Duties and Responsibilities of this Level


  • Leads initiatives to create an exceptional culture of safety where all caregivers and providers are empowered to identify quality and safety improvement opportunities as well as the ability to “stop the line” when clinically appropriate.
  • Embraces Lean thinking and fosters relationships with medical staff to inspire, motivate and lead a culture of process improvement within the organization.
  • Supports system leadership in the execution of strategies impacting the safety of care delivery programs.
  • Partners with hospital and physician leadership, operational leaders and safety and quality teams to ensure that organizational wide safety and quality goals and objectives and risk reduction strategies are implemented effectively wherever appropriate while engaging stakeholders in the process.
  • Manages safety improvements through standardization, risk mitigation plans, and implementation of best practices impacting care delivery and provider practices. Develops and annually reviews the patient safety program with focused programs and improvements based on internal needs and external requirements and standards.
  • Oversees the goals and plans for the department and team, develops tactical strategies to achieve desired vision.  Provides strategic ROI analysis for safety initiatives; and manages recommendations, reviews and approves metrics.
  • Oversees Root Cause Analysis activities evaluating sentinel and other adverse events. Supports the review, investigation and analysis of major adverse events and ensures appropriate trainings and corrective actions are taken to prevent recurrences.  Manages the overall process and improvements for the review, investigation and closure of appropriate Safety Alert System reports.
  • Conducts regular reviews of Duke University Hospital’s safety and quality performance in partnership with medical staff, quality, and leadership teams across the organization, providing expectations, performance planning, feedback, training, development and performance discussions; defining future state requirements for operations and ensures the implementation of strategies and initiatives to effectively meet or exceed business and patient expectations.
  • Serves as a visible and engaged leader that energizes and communicates effectively with providers, leadership and staff.  Hires, leads, coaches and monitors the performance of all direct reports, to develop and maintain a high performance team that meets organizational and department goals.
  • Adheres to the latest thinking in both inpatient and ambulatory quality, patient safety and patient engagement.  Monitors literature and professional organizations for new and revised best practices related to patient safety, serves as a knowledge leader within the industry.


Minimum Qualifications:



A Master’s degree in a healthcare field, nursing or related discipline is required.



Work requires a minimum of 5 years of recent hospital experience in quality or safety, in a leadership capacity including regulatory survey preparation and standards compliance, infection prevention/control or a related area. Infection control experience and knowledge of Lean Six Sigma practices is preferred.



Patient Safety Certification is required.


Valid North Carolina license or temporary permit to practice professional nursing.




Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.


Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.


Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.


Nearest Major Market: Durham
Nearest Secondary Market: Raleigh