Canyon Vista Medical Center - sierra Vista, AZ

Director of patient safety And Quality

Job Summary

director of patient safety & quality

We are looking for a registered nurse to step into the role of Quality and Patient Safety Director at a 106 bed hospital in Arizona. You will manage the daily activities of the quality and patient safety departments, and ensure regulatory compliance and accreditation. You will have the opportunity to work in collaboration with hospital leadership, medical staff, and the hospital service center.


canyon vista medical center

Located in the beautiful high desert of southeastern Arizona, Canyon Vista Medical Center commits to serve residents in Sierra Vista, Ft. Huachuca, Cochise County – a population of more than 131,000 people, and our surrounding communities. We’re comfortably nestled in the San Pedro River Valley, 75 miles southeast of Tucson.

Canyon Vista Medical Center was founded in 1963 as Western Baptist Osteopathic Hospital on what was then the eastern edge of Sierra Vista. Growth and advancing technology dictated building our new 177,000 square foot hospital at 5700 E Hwy 90.

About the town

sierra vista, AZ


Public Schools




Good for Familes




Cost of Living


Outdoor Activities


Crime & Safety








Health & Fitness



Leapfrog Hospital Safety Scores

canyon vista medical center

MeasureThe Hospital’s ScoreWorst Performing HospitalAvg. Performing HospitalBest Performing HospitalData SourceTime Period Covered
Dangerous object left in patient’s body What’s This?0.0000.3730.020.000CMS07/01/2018 – 12/31/2019
Air or gas bubble in the blood What’s This?0.0000.642.00160.000CMS07/01/2018 – 12/31/2019
Patient falls and injuries What’s This?0.6912.0750.420.000CMS07/01/2018 – 12/31/2019
Infection in the blood What’s This?1.3364.6201.050.0002021 Leapfrog Hospital Survey10/01/2019 – 12/31/2019 and 07/01/2020 – 03/31/2021
Infection in the urinary tract What’s This?0.4033.3370.850.0002021 Leapfrog Hospital Survey10/01/2019 – 12/31/2019 and 07/01/2020 – 03/31/2021
Surgical site infection after colon surgery What’s This?Not Available2.7650.790.0002021 Leapfrog Hospital Survey10/01/2019 – 12/31/2019 and 07/01/2020 – 03/31/2021
MRSA Infection What’s This?Not Available4.0331.030.0002021 Leapfrog Hospital Survey10/01/2019 – 12/31/2019 and 07/01/2020 – 03/31/2021
C. diff. Infection What’s This?0.1851.7830.520.0002021 Leapfrog Hospital Survey10/01/2019 – 12/31/2019 and 07/01/2020 – 03/31/2021
Death from treatable serious complications What’s This?147.57206.08159.6895.65CMS07/01/2018 – 12/31/2019
Harmful Events What’s This?0.883.341.000.60CMS07/01/2018 – 12/31/2019
      Dangerous bed sores What’s This? *0.308.780.580.04CMS07/01/2018 – 12/31/2019
      Collapsed lung What’s This? *0.210.480.230.12CMS07/01/2018 – 12/31/2019
      Falls causing broken hips What’s This? * – 12/31/2019
      Blood Leakage What’s This? *2.415.582.541.26CMS07/01/2018 – 12/31/2019
      Kidney injury after surgery What’s This? *1.403.451.420.58CMS07/01/2018 – 12/31/2019
      Serious breathing problem What’s This? *4.5617.095.181.66CMS07/01/2018 – 12/31/2019
      Dangerous blood clot What’s This? *3.258.413.611.65CMS07/01/2018 – 12/31/2019
      Sepsis infection after surgery What’s This? *5.119.734.962.31CMS07/01/2018 – 12/31/2019
      Surgical wound splits open What’s This? *0.841.540.860.57CMS07/01/2018 – 12/31/2019
      Accidental cuts and tears What’s This? *1.103.971.210.37CMS07/01/2018 – 12/31/2019
* This measure is a part of the Harmful Events Composite and is not used for scoring.

Process measures include the management structures and procedures a hospital has in place to protect patients from errors, accidents, and injuries.

MeasureThe Hospital’s ScoreWorst Performing HospitalAvg. Performing HospitalBest Performing HospitalData SourceTime Period Covered
Doctors order medications through a computer What’s This?100586.601002021 Leapfrog Hospital Survey2021
Safe medication administration What’s This?75584.181002021 Leapfrog Hospital Survey2021
Specially trained doctors care for ICU patients What’s This?5564.461002021 Leapfrog Hospital Survey2021
Effective leadership to prevent errors What’s This?120.0046.15117.09120.002021 Leapfrog Hospital Survey2021
Staff work together to prevent errors What’s This?120.000.00116.88120.002021 Leapfrog Hospital Survey2021
Enough qualified nurses What’s This?100.000.0098.36100.002021 Leapfrog Hospital Survey2021
Handwashing What’s This?1001576.221002021 Leapfrog Hospital Survey2021
Communication with nurses What’s This?907590.2596CMS07/01/2020 – 03/31/2021
Communication with doctors What’s This?907790.1897CMS07/01/2020 – 03/31/2021
Responsiveness of hospital staff What’s This?816382.1793CMS07/01/2020 – 03/31/2021
Communication about medicines What’s This?745775.2489CMS07/01/2020 – 03/31/2021
Communication about discharge What’s This?876585.7395CMS07/01/2020 – 03/31/2021

Hospital Leadership

MEET THE staff

Sonni Burrell

Director of HR

William Kiefer

Chief Operating Officer

Official job description

canyon vista medical center- Director of patient safety & QUALITY

Position Summary/Description:
The Patient Safety and Quality works collaboratively with the senior leadership team, department directors, and medical staff to lead, develop and oversee a best-in-class hospital quality and safety program and to ensure regulatory compliance and accreditation.

Job Duties
1. Participate in hospital activities as a member of the leadership team.
2. Role model for compliant behavior consistent with the mission, vision, and values of LifePoint and the hospital.
3. Oversee the direct operations of the Quality Department, including Risk, Infection Prevention, Patient Satisfaction and Trauma Coordination.
4. Motivate, mentor, develop and evaluate staff in the Quality Department.
5. Promotes a culture of safety, high-reliability, patient and staff engagement, and performance excellence.
6. Regularly communicate quality, performance improvement, regulatory compliance and safety activities to the medical staff, executive team, hospital leaders and Board of Trustees
7. Lead the development of hospital policies and procedures related to quality improvement and patient safety.
8. Develop long-range goals, annual objectives and strategies for areas of responsibility.
9. Aid in the organization and implementation of the hospital and Board safety and quality committees and key strategic patient safety and quality initiatives

Quality Assurance and Performance Improvement
1. In collaboration with hospital leadership, medical staff, and the Hospital Service Center (HSC) participate in the development, monitoring, reporting and improvement of activities related to hospital quality and safety in order to achieve organizational targets and goals.
2. Collaborate with hospital and physician leaders to envision, develop, and implement the organization’s comprehensive safety and quality program.
3. Oversees reporting and communication of quality improvement initiatives, quality and patient safety awareness, safety culture survey administration, and recognition programs. (Including reports for Medical Staff Committees, Board of Trustees, MOR, etc)
4. Participates in root cause analyses and failure modes and effects analyses and debriefings.
5. Takes a lead role in the LeapFrog Survey, Culture of Safety Survey, and implementation/monitoring of the National Quality Program.
6. Ensures timely submission of Quality data to the HSC, LeapFrog, Quality Net, HIIN, NHSN, National Quality Program and other required agencies.
7. Advanced Process Improvement Knowledge and Experience

Regulatory Readiness
1. Directs and coordinates accreditation strategies to ensure compliance with State, Joint Commission and Medicare Conditions of Participation.
2. In collaboration with Compliance, Risk Management, and Legal, oversee the investigation and reporting of events as required by regulatory agencies and serves as a physician liaison in PI efforts related to medical safety.
3. Coordinate and oversee data collection and analysis, reporting, improvement activities and follow-up related to serious safety events via the Patient Safety Organization.
4. Devise, implement and coordinate a plan for JC tracer activities.

Position Requirements:
Complies with legal, hospital and departmental policies, procedures and position requirements. Must have an active RN License (AZ within 60 days of hire). Must have an associate degree in Nursing, bachelor degree preferred.

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Most frequent questions and answers

Yes. All of our open positions come with some sort of relocation allowance to help with the expenses of relocating. 

Yes. We will prep you for every interview you take. We know what our clients are looking for, so we will let you know what to expect and what experiences and accomplishments you should be sure to communicate to them in an interview.

Yes. If you connect us with another Infection Prevention professional that is interested in this position, and ultimately gets hired – we will send you a $500 referral bonus. 

Of course. We work to get you the highest possibly financial package – and communicate our progress throughout the process. We are financially incentivized to get you the most lucrative offer possible. 

Absolutely. We will review your resume before we submit it to the client to make sure it communicates everything it needs to.

First, everything we offer to our candidates is completely FREE. 

We operate as advisors and consultants for your Infection Prevention career. We’ve recruited in this industry for a long time and understand the profession as well as anyone.

If you decide you’d like us to represent you and apply for a position, the first thing our team will do is examine your resumé closely. We will fix up your resumé to ensure it communicates exactly what our client is looking for – demonstrating not only what you’ve been responsible for in previous Infection Prevention positions, but also how effective you’ve been in those roles. 

We have direct access to the hiring managers in the positions we search on which allows us to present your resumé directly to them, knowing exactly what they want to see in a candidate. We will keep you in the loop when this happens and what their initial feedback is. No more waiting in the dark hoping to hear back from HR.

Because of our relationships with the hiring manager, we have the ability to make a case for them to speak with you. It also allows us to get quick, honest feedback following each interview you have. And we will provide that feedback to you, good or bad.

In addition to preparing your resumé and presenting directly to the hiring manager, we also will prep you for each and every interview. Again, we know what our clients are looking for, so we will let you know what to expect and what experiences and accomplishments you should be sure to communicate to them in an interview.

In terms of the interview process, we’ll work with you and the client to get those scheduled during a time that makes sense for you.

Perhaps the most beneficial piece of being represented by Clutch Recruitment is that we’ll negotiate an offer for you – securing the highest possible offer the client can make. Don’t worry about your salary demands rubbing your future employer the wrong way;  we do all of that for you, ensuring a completely fair offer, without the awkwardness that potentially comes with it. We are financially incentivized to get you the highest possible offer, and we will ensure that happens.

Once you accept an offer, our work doesn’t stop. We’ll be there to talk you through your resignation and prepare you for how to handle a counter offer, along with all other complications that may arise. 

We have a large in house sourcing team that collects information from various databases online including LinkedIn, certification boards, and professional associations. 

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