REPORTING RELATIONSHIPS/SUPERVISORY RESPONSIBILITIES
The Director of Medication Safety, Quality, and Regulatory Compliance will supervise system-wide initiatives for medication safety, regulatory compliance, and quality improvement. The position will oversee subordinate managers, lead committees, and collaborate with leaders across the organization to achieve system-wide safety and performance objectives. Direct Reports: Managers and staff responsible for medication safety, patient safety, quality improvement efforts, and regulatory compliance.
POSITION SUMMARY
The Director of Medication Safety, Quality, and Regulatory Compliance leads the development and execution of system-wide strategies to enhance medication and patient safety, ensure regulatory compliance, improve quality of care, and optimize performance. This position requires collaboration with clinical and administrative leaders to promote a culture of safety, standardize workflows, and proactively address risks across the healthcare system.
ACCOUNTABILITIES
*All duties listed below are essential unless noted otherwise*
Core Accountabilities
1. Development and Management of Department or Program Across the Pharmacy Enterprise
• Leads and standardizes system-wide medication safety, quality, and regulatory compliance initiatives.
• Chairs the Medication Safety Committee to align safety strategies with enterprise goals.
2. Financial Management and Budgetary Oversight
• Manages the budget, allocates resources for improvement initiatives, and identifies cost-saving opportunities.
3. Management Responsibilities as a Senior Leader
• Provide mentorship to subordinate managers and ensure staff competency in medication safety practices.
• Participates in system-wide strategic planning and decision-making.
4. Job-Specific Accountabilities
• Leads root cause analyses (RCA), failure mode effects analyses (FMEA), and other performance improvement initiatives.
• Ensures compliance with regulatory and accreditation requirements, including Joint Commission, CMS, and ISMP guidelines.
• Collaborates with IT and clinical departments to enhance technology use and implement safety tools.
5. Execution of Department and Organizational Strategies, Goals, and Business Objectives
Implements strategic initiatives aligned with system priorities.
Develops and executes a multi-year plan to mitigate risks and improve safety outcomes.
6. Performs other duties as assigned.
Key Job Responsibilities
• Medication Safety Program Leadership: This position leads system-wide initiatives to improve medication safety, including chairing the Medication Safety Committee, coordinating RCAs, and implementing strategies to reduce adverse drug events (ADEs).
• Regulatory Compliance: Ensures adherence to federal, state, and local regulations (e.g., FDA, DEA, CMS) and accreditation standards (e.g., Joint Commission). Leads internal audits and oversees preparations for external audits and inspections.
• Policy and Procedure Standardization: Develops and implements standardized pharmacy policies and procedures across the system to ensure consistent and safe medication practices.
• Data Analysis and Reporting: Monitors and analyzes key performance indicators (KPIs) and safety metrics. Prepares reports and dashboards to support data-driven improvements.
Quality Improvement Initiatives: Coordinates performance improvement projects using methodologies such as Lean, Six Sigma, and human factors engineering to enhance safety and operational efficiency.• Collaboration and Communication: Acts as a liaison across pharmacy, nursing, providers, and other stakeholders to foster collaboration and promote a culture of safety and transparency.
• Education and Competency Development: Designs and delivers system-wide training programs to enhance staff proficiency in medication safety and regulatory compliance.
• Technology Optimization: Partners with IT and informatics teams to optimize clinical systems and electronic health records (EHR) to reduce medication errors.
• Change Management: Leads system-wide change management initiatives to support the implementation of new safety protocols and regulatory processes.