Manager- Quality, Safety & Accreditation

Manager Of Quality, Safety And Accreditation

At Gillette Children's, we believe every child deserves the safest, highest-quality care possible. The Manager of Quality, Safety and Accreditation plays a central role in making that a reality. This leader drives the strategy and day-to-day execution of Gillette's quality improvement, infection control surveillance and prevention, patient safety, and accreditation programs. This is a highly visible, collaborative role for someone who thrives at the intersection of data, people, and systems change. The manager will partner with clinical and operational leaders across the organization to build and sustain a culture where safety is everyone's responsibility and continuous improvement is a shared value.

This is a hybrid position with a minimum expectation of working onsite 50% of the time. The primary work location is our main campus in downtown St. Paul.

Compensation & Benefits

The annual salary range for this opportunity is $ 117,478 to $ 176,217, with a median salary of $ 146,848 /annually . Pay is dependent on several factors including relevant work experience and internal equity. Salary is just one component of the compensation package for employees. Gillette supports career progression and offers a competitive benefits package, including a retirement saving match, tuition and certification reimbursement, paid time off, and health and wellness benefits for.5 FTE and above.

Primary Job Responsibilities

• Own the strategy and execution of Gillette's quality improvement, patient safety, infection prevention, and accreditation preparedness review programs.
• Partner with clinical and operational leaders to build systems that proactively identify risk, reduce harm, and create lasting improvements in care delivery.
• Lead the organization's event review process, including serious safety event (SSE) investigations, root cause analyses, and follow-through on corrective actions.
• Oversee the infection control and prevention program.
• Champion a just culture and high-reliability mindset throughout the organization, helping teams move from reactive to proactive safety practices.
• Serve as a visible and trusted resource for staff at all levels who want to raise safety concerns or improve care processes.

Accreditation and Regulatory Compliance

• Maintain continuous survey readiness for all applicable regulatory bodies, including but not limited to the Joint Commission, CARF, CAP, etc.
• Lead the planning, coordination, and response for all accreditation surveys, including unannounced visits.
• Track regulatory changes and translate new requirements into actionable plans for impacted departments.
• Ensure timely resolution of survey findings and deficiencies in partnership with operational leaders.
• Serve as the organization's primary point of contact for accreditation bodies and regulatory agencies.

Data, Analytics, and Reporting

• Develop and maintain quality dashboards and scorecards that provide clear, real-time visibility into performance across safety, quality, and compliance metrics.
• Provide regular quality and safety reports to senior leadership, the Quality and Safety Committee of the Board, and relevant internal committees.
• Use data analytics, including predictive tools where available, to identify emerging risks and improvement opportunities.
• Support departments in building their own measurement capabilities so quality improvement is distributed, not centralized.

Education, Training, and Team Development

• Design and deliver quality and safety education for clinical and non-clinical staff during onboarding and on an ongoing basis.
• Build the organization's internal capacity for performance improvement through coaching, mentoring, and hands-on facilitation support.
• Lead, develop, and manage a team of quality and safety professionals, fostering a collaborative, high-performing department culture.
• Represent Gillette Children's at external quality and safety forums, contributing to the broader learning community.

Departmental Management

• Manage department budget, staffing, and operations within established financial parameters.
• Conduct regular performance evaluations and provide ongoing, meaningful feedback to direct reports.
• Collaborate with the COO and other senior leaders on strategic planning and priority-setting for quality and safety.

Qualifications

Required

• Bachelor's degree in healthcare administration, public health, nursing, business, or related field. A master's degree is strongly preferred.
• Five or more years of progressive experience in quality, patient safety, or accreditation in an acute care or specialty hospital setting.
• Certified Professional in Healthcare Quality (CPHQ) or commitment to obtain certification within one year of hire.

Knowledge, Skills and Abilities

• Knowledge of hospital quality systems, patient safety science, evidence-based practice standards (including NIH-aligned frameworks), CMS Conditions of Participation, state regulations, and accreditation requirements, with demonstrated experience leading accreditation surveys and maintaining ongoing readiness.
• Proven ability to use data to drive decision-making, including experience with performance dashboards, outcome metrics, quality reporting tools, and translating complex data into compelling narratives that motivate action at all organizational levels.
• Expertise in quality improvement and patient safety methodologies, including root cause analysis, failure mode and effects analysis (FMEA), systems thinking, and the design and implementation of sustainable organization-wide improvement initiatives.
• Demonstrated success leading cross-functional teams, building strong partnerships with clinical and administrative stakeholders, and coaching others in quality improvement principles and practices.
• Strong leadership, change management, and facilitation skills, with the ability to navigate ambiguity, engage teams, and drive results in complex environments.
• Excellent written, verbal, and presentation skills, with the ability to communicate complex concepts clearly and effectively to diverse audiences.
• Experience managing budgets, leading direct reports, and overseeing departmental operations.
• Proficiency with electronic health record (EHR) platforms, quality management systems, and data visualization and reporting tools.
• Commitment to health equity and an understanding of how bias and social determinants of health influence patient safety, quality outcomes, and care delivery.
• Exceptional organizational skills with the ability to manage multiple priorities while maintaining attention to detail.

Preferred

• Experience in a pediatric, rehabilitation, or complex care specialty setting.
• Lean, Six Sigma, Evidence-Based Practice, or other structured performance improvement certification or training.
• Familiarity with high-reliability organization (HRO) principles and implementation.
• Experience presenting at regional or national quality and safety conferences.
• Knowledge of emerging technologies in quality management, including predictive analytics and AI-enabled safety tools.