Reporting to the Chief Medical Officer, you will ensure that performance improvement and clinical activities are coordinated, aligned to and supporting the goals and mission of the Hospital You will provide consultation and skill development in performance improvement activities to the Medical Staff, executive and management leadership and staff, as well as organization-wide coordination for all aspects of regulatory compliance, including licensure and accreditation You will provide direction for all functions related to the Quality Management, Risk Management, Infection Control, Patient Safety, and Regulatory Compliance You will coordinate Hospital activities related to process and outcome data collection and assessment, and the use of process and outcome data in performance improvement activities You will ensure operations run within budgetary guidelines, be responsible for positive employee engagement and appropriate communication with staff, and for quality and performance improvement activities You will be responsible for ensuring compliance with all applicable regulations and guidelines as set by federal, state, local and other agencies (i.e, JCAHO, Medicare, CMS) and facilitate positive productive relationships with physicians What qualifications you will need: M.A. / M.S. required CPHQ Certification required within 1 year of hire 7-9 years of progressive hospital/nursing management experience, or an equivalent combination of education and experience required Exhibit experience which defines competency in Quality Management, Risk Management, Infection Control, and Regulatory Compliance, hospital and healthcare management, and experience in successful administration and leadership of organizational management programs Good Samaritan Hospital has been serving Silicon Valley since 1965, giving patient's access to highly-trained physicians and advanced technology.