Manager- Quality, Safety & 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.

About the role

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. 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.

Responsibilities

• Quality and Patient Safety Leadership
  • 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.

Requirements

• 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.
• Previous management experience or other leadership experience.
• Certified Professional in Healthcare Quality (CPHQ) or commitment to obtain certification within one year of hire.

Skills

• 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 Qualifications

• 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.

Pay

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.

Benefits

• Retirement saving match
• Tuition and certification reimbursement
• Paid time off
• Health and wellness benefits for .5 FTE and above