Director of Peri-Operative Quality Improvement at CareWell Health – East Orange, New Jersey

Job Summary

The Director of Peri-Operative Quality Improvement plays a critical leadership role in an acute care hospital setting, overseeing surgical quality initiatives, patient safety programs, and regulatory compliance within the perioperative and surgical service lines. This position ensures that surgical care delivered in the hospital adheres to the highest standards of quality, safety, and effectiveness. The Director collaborates closely with physicians, nursing leaders, infection preventionists, and quality management teams to optimize surgical outcomes and maintain full readiness for regulatory and accreditation surveys.

Essential Functions:

Lead the hospital’s surgical quality and patient safety strategy, aligning with organizational goals and national benchmarks.

Develop and implement quality improvement initiatives to reduce surgical site infections, enhance patient outcomes, and ensure compliance with CMS, Joint Commission, and state regulatory bodies.

Facilitate and lead surgical case reviews, morbidity and mortality conferences, and root cause analyses (RCA).

Act as a liaison between surgical teams, hospital administration, and external regulatory bodies.

Ensure consistent monitoring and reporting of surgical performance metrics, including infection rates, readmissions, complication rates, and patient satisfaction.

Collaborate with OR leaders, surgeons, anesthesia, sterile processing, and nursing to ensure adherence to evidence-based practices and standard operating procedures.

Prepare for and participate in accreditation surveys, including those by The Joint Commission, CMS, and state departments of health.

Support staff education and training on surgical safety protocols, time-outs, and incident reporting.

Monitor compliance with policies such as Universal Protocol, surgical checklists, and surgical count procedures.

Technology: Proficient in use of health care technology. Skilled in technology-based operational improvement: auditing, data aggregation, monitoring. Proficiency in Microsoft Applications: Word, Excel, Powerpoint, Outlook required.

Other Duties
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Minimum Education/Certification:

RN licensure in New Jersey (NJ) strongly preferred.

Bachelor’s degree in Nursing, Healthcare Administration, or related field required.

Master’s degree (MSN, MPH, MHA, or MBA) strongly preferred.

Certification in Healthcare Quality (CPHQ), Patient Safety (CPPS), or related certification preferred.

Minimum Work Experience:

Minimum of 5–7 years of experience in surgical services or perioperative leadership within an acute care hospital.

Health care management or consulting experience preferred