Job Description

Job Title:                       RN Quality and Patient Safety Officer   

Reports To:                   CCIO   

Job Summary:                   This position prioritizes a high reliability focus on quality and safety.  Role responsibilities include assessing quality and safety performance throughout the organization with oversight of performance improvement projects.  This position works closely with both system and operating entities to improve quality, safety and outcomes in clinical care and working environment.


Essential Job Duties and Responsibilities:

The job duties and responsibilities listed below are representative of the knowledge, skill, and/or ability required.  Other duties that fall within the broad scope of this classification may be assigned.

Quality Review Responsibilities

  • Assists in the development and review of the clinical medical record, including Peer Review processes, quality of care concerns, standards of documentation for quality, credentialing, or regulatory agencies.
  • Assists in the assessment of clinical performance data and care delivery practices.
  • Assists and conducts in-depth assessment of qualitative and quantitative data.
  • Triangulates information gained to support administrative and clinical decision making.
  • Collaborates with administrators, providers, leadership, and staff to identify quality and/or safety improvements using quantitative techniques.
  • Uses literature, evidenced-based practice, and benchmark data whenever possible.
  • Improves clinical performance through identification of variation and supports implementation of systems and processes to facilitate effective clinical practice.
  • Leverages results from Peer Review, Regulatory, Patient Safety and others to align performance improvement opportunities with all departments.
  • Facilitates prioritization and collaboration of improvement activities with appropriate leadership.
  • Assists in review of incidents concerning quality processes.

Safety Officer Responsibilities

  • Assists Compliance/Risk Officer in review, development and training of Quality, Safety and Compliance.
  • Identifies and evaluates for potential safety risks and potential loss, recommends solutions for reducing risk.
  • Leads organization in safety policy development and review.
  • Develops and conducts training programs, policies and procedures required for safety improvement and governmental regulation.
  • Leads organization in safety equipment purchases and review.
  • Keeps up to date on safety laws and policies and informs management of new or updated regulations, their requirements and impact.
  • Develops and monitors the implementation and effectiveness on policies, procedures and guidelines that affect safety of employees and that of patients and visitors.
  • Assists in the review of incidents concerning safety measures.


  • Lead Project Management efforts for multiple projects.
  • Work with leadership to critically assess status Quality and Safety concerns, workflows and creativity explore and develop solutions to ensure that clinical processes are data driven.
  • Identify and oversee collaborative partnerships with interdepartmental and third-party stakeholders to ensure Chiricahua Mission and Vision.

Minimum Qualifications - Education, Experience, Certificates & Licenses:

  • Requires Bachelor’s degree or equivalent in Nursing.
  • RN license in AZ required.
  • Must have 5 years’ experience in Quality / Performance Improvement.
  • 2 years successful large scale project management experience.
  • At least 2 years clinical experience. May be overlapping experiences.

Preferred Qualifications:

  • CPHQ or similar preferred.
  • Safety certificate preferred.


Required Language Skills:

  • Ability to comprehend and compose instructions, correspondence, and communications in English in both oral and written format.
  • Bilingual in English and Spanish is preferred, but not required.


Physical Requirements:

  • Ability to frequently exert enough force to move objects weighing up to 25 pounds.
  • Ability to continuously remain in a stationary position.
  • Ability to frequently move about inside the workplace to assist patients, operate office or medical equipment, etc.
  • Possesses hand-eye coordination and manual dexterity necessary to constantly operate computer, telephone, and other office machinery.
  • Possesses close visual acuity necessary to accurately record and view information on a computer monitor, handwritten and typed documents.
  • Ability to discern the nature of sounds at a normal spoken volume.


Other Required Knowledge, Skills, and Abilities:

  • Ability to perform basic medical math that may include the use of ratio/proportion, dosage calculation, metric and household equivalents, roman numerals, abbreviations, and general math including percentages, etc.
  • Ability to gather data in an organized fashion from varied sources.
  • Ability to perform variety of assignments requiring independent judgment.
  • Ability to resolve challenges and work under pressure.
  • Knowledge of health plans and community health centers preferred.
  • Knowledge of HIPAA rules and regulations.
  • Computer literacy required.
  • Knowledge of Electronic Health Records preferred.


Work Environment & Conditions:

  • Work environment is typical of a health clinic setting with occasional exposure to communicable diseases, bodily fluids, and hazardous chemicals.
  • Occasionally, work requires extended hours to include early mornings, evenings, and weekends.