Christus St. Vincent Regional Medical Center -
Sante Fe, New Mexico

Director of quality, patient safety, accreditation

Job Summary

Director of quality, patient safety, accreditation

We are looking for a quality professional to step into the role of Program Manager of Quality at Christus St. Vincent Regional Medical Center in Santa Fe, New Mexico. You will lead the Quality department and lead Performance Improvement programs at this 203 bed hospital. You will report to the Executive Director of Performance Improvement. 

You will need a Bachelor’s Degree in nursing or a health-related field, or must actively be pursuing a Bachelor’s Degree. A Master’s Degree is preferred, along with a current New Mexico or compact RN license. You will be required to obtain your CPPS and CPHQ within two years of hire. You will need one year of management experience, including experience in facilitating interdisciplinary team collaboration; as well as three years of project management experience, including experience or knowledge of performance improvement process, quality management activities, performance measures, and evidence based practices.

Christus St. Vincent Regional Medical Center in Santa Fe, NM is rated high performing in 6 adult procedures and conditions. It is a general medical and surgical facility. The evaluation of Christus St. Vincent Regional Medical Center also includes data from CHRISTUS St. Vincent Physicians Medical Center. CHRISTUS Health, a Catholic health ministry, will be a leader, a partner and an advocate in the creation of innovative health and wellness solutions that improve the lives of individuals and communities so that all may experience God’s healing presence and love. More than 45,000 dedicated team members, including 15,000 clinicians, provide personalized care to neighbors across the globe.

Santa Fe, New Mexico’s capital, sits in the Sangre de Cristo foothills. It’s renowned for its Pueblo-style architecture and as a creative arts hotbed. Founded as a Spanish colony in 1610, it has at its heart the traditional Plaza. The surrounding historic district’s crooked streets wind past adobe landmarks including the Palace of the Governors, now home to the New Mexico History Museum. With legendary history and culture around every corner, an art scene that spans from traditional to contemporary, accommodations with a local feel yet world-class status, and award-winning cuisine that’s as eclectic as it is sumptuous, there are countless of experiences to encounter in Santa Fe. 

Christus St. Vincent regional medical center

Located in Santa Fe, the 200-bed hospital operates under a 50/50 partnership with CHRISTUS Health and local community health impact organization, Anchorum St. Vincent. Together, our hospital and outpatient clinics provide the more than 300,000 residents of north-central New Mexico with access to 39 services and lines of specialty care.


About the town

Sante Fe, NM


Public Schools




Good for Familes




Cost of Living


Outdoor Activities


Crime & Safety








Health & Fitness



Leapfrog Hospital Safety Scores

Christus St. Vincent Regional 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?0.4062.0750.420.000CMS07/01/2018 – 12/31/2019
Infection in the blood What’s This?1.5484.6201.050.0002021 Leapfrog Hospital Survey10/01/2019 – 12/31/2019 and 07/01/2020 – 03/31/2021
Infection in the urinary tract What’s This?0.8483.3370.850.0002021 Leapfrog Hospital Survey10/01/2019 – 12/31/2019 and 07/01/2020 – 03/31/2021
Surgical site infection after colon surgery What’s This?0.6152.7650.790.0002021 Leapfrog Hospital Survey10/01/2019 – 12/31/2019 and 07/01/2020 – 03/31/2021
MRSA Infection What’s This?0.8714.0331.030.0002021 Leapfrog Hospital Survey10/01/2019 – 12/31/2019 and 07/01/2020 – 03/31/2021
C. diff. Infection What’s This?0.4981.7830.520.0002021 Leapfrog Hospital Survey10/01/2019 – 12/31/2019 and 07/01/2020 – 03/31/2021
Death from treatable serious complications What’s This?181.97206.08159.6895.65CMS07/01/2018 – 12/31/2019
Harmful Events What’s This?0.793.341.000.60CMS07/01/2018 – 12/31/2019
      Dangerous bed sores What’s This? *0.198.780.580.04CMS07/01/2018 – 12/31/2019
      Collapsed lung What’s This? *0.240.480.230.12CMS07/01/2018 – 12/31/2019
      Falls causing broken hips What’s This? * – 12/31/2019
      Blood Leakage What’s This? *2.565.582.541.26CMS07/01/2018 – 12/31/2019
      Kidney injury after surgery What’s This? *1.323.451.420.58CMS07/01/2018 – 12/31/2019
      Serious breathing problem What’s This? *4.6217.095.181.66CMS07/01/2018 – 12/31/2019
      Dangerous blood clot What’s This? *2.988.413.611.65CMS07/01/2018 – 12/31/2019
      Sepsis infection after surgery What’s This? *4.259.734.962.31CMS07/01/2018 – 12/31/2019
      Surgical wound splits open What’s This? *0.821.540.860.57CMS07/01/2018 – 12/31/2019
      Accidental cuts and tears What’s This? *0.913.971.210.37CMS07/01/2018 – 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?100584.181002021 Leapfrog Hospital Survey2021
Specially trained doctors care for ICU patients What’s This?100564.461002021 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?917590.2596CMS07/01/2020 – 03/31/2021
Communication with doctors What’s This?907790.1897CMS07/01/2020 – 03/31/2021
Responsiveness of hospital staff What’s This?886382.1793CMS07/01/2020 – 03/31/2021
Communication about medicines What’s This?745775.2489CMS07/01/2020 – 03/31/2021
Communication about discharge What’s This?836585.7395CMS07/01/2020 – 03/31/2021

Hospital Leadership

MEET THE staff

Michael Silva

Healthcare Recruiter

Reymundo Holguin

Talent Acquisition Manager

Official job description

Christus St. Vincent regional medical center

Job Description:

The Director establishes and sustains organization-wide processes and systems to maintain compliance with The Joint Commission (TJC) and Center for Medicare and Medicaid Services (CMS) standards. The function works with senior Leadership and the Leadership team (directors and managers) to direct and manage interdisciplinary teams to achieve continuous readiness with regulatory compliance. The Director has the direct responsibility for assessing the organization’s compliance status, educating to The Joint Commission and CMS requirements, meeting regulatory deadlines and chairing the Continuous Survey Readiness Committee. This individual develops the goals and objectives for accreditation readiness, patient safety and quality

In addition, the Director has responsibility for coordinating and overseeing the development of comprehensive patient safety improvement initiatives to reduce medical errors and healthcare incidents and s/he leads the hospital’s efforts related to promoting a just culture. The Director works collaboratively with executives, administrators, doctors, and nursing to develop effective strategies that boost patient safety. The Director advises risk, and guides clinical leaders, medical staff, operational leadership, and associates in a continual pursuit of patient safety improvement opportunities and promotes and vigorously supports a comprehensive culture of patient safety throughout the organization. The Director has primary oversight of the patient safety program under the direction of the regional PSO and collaborates with leadership to develop policies and procedures affecting organizational patient safety. The Director alerts leadership and the Quality Outcomes Committee to real or potential system-based causes of negative outcomes to patient safety.

NO travel required

EDUCATION: Bachelor’s Degree in nursing or health-related field required, or must actively be pursuing a BS/BA. MS preferred.

CERTIFICATION/LICENSES: Current New Mexico or compact RN license preferred. Obtain the Certified Professional in Patient Safety (CPPS) credential through the National Patient Safety Foundation (NPSF) within two years. Obtain Certified Professional in Healthcare Quality (CPHQ) from National Association of Healthcare Quality within two years.

Knowledge of TJC standards and Patient Safety core principles is essential
Effective change agent
Facilitative leadership skills
Strong interpersonal skills including mentoring and coaching
Strong problem solving ability
Good analytical and mathematical skills are required
Effective oral, written and presentation skills. Proficient computer, research and data management skills.
Demonstrated ability to make public presentations to both large and small groups, and to articulate information or data to multiple audiences with varying degrees of knowledge and expertise
Evidence of capability should include:
Strong leadership qualities (task completion, motivation)
Project management, implementation and monitoring abilities
Ability to establish and sustain processes and systems for continuous performance improvement
Ability to plan, organize, direct, and manage the activities of others
Ability to set, negotiate and achieve accountability for leadership and associate teams action, outcomes and deadlines with leadership and associate teams
Possesses knowledge of regulatory and accreditation requirements, and national patient safety goals
Ability to analyze and establish actions to achieve performance improvement
Ability to analyze and report data in a meaningful and useful manner
Ability to motivate others as individuals and as a team.
Ability to communicate with a wide variety of audiences.
Experience in collaborating with licensed independent practitioners (LIPs), LIP advisors and medical directors
Working knowledge of quantitative analysis tools, MS Office applications including as Outlook, Word, PowerPoint, and Excel.
Demonstrates patience and perseverance to accomplish clinical quality improvement

EXPERIENCE: One year of management experience including experience in facilitating interdisciplinary team collaboration required. Three years project management experience required, including experience or knowledge of performance improvement process, quality management activities, performance measures and evidence based practices

-Responsible to: Executive Director of Performance Improvement

-Bloodborne pathogen: A
Works in a clean, well-lighted, ventilated smoke-free environment.

PHYSICAL REQUIREMENTS: Working hours vary, with flexibility due to unexpected changes in schedule and emergencies. Requires the ability to speak, listen, develop and communicate written materials. Requires the ability to lift at least 20 lbs.

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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. 

our team

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