Director of Quality, Safety, & Infection Control

Job description

University of Colorado | CU Anschutz Medical Campus

School of Medicine Dean’s Office Community Practices

Health Care Director, Director of Quality, Safety, & Infection Control

Position #780191 – Requisition #20784

* Applications are accepted electronically ONLY at *

The University of Colorado Anschutz Medical Campus seeks individuals with demonstrated commitment to creating an inclusive learning and working environment. We value the ability to engage effectively with students, faculty and staff of diverse backgrounds.

School of Medicine Dean’s Office Community Practices has an opening for a [full-time] University Staff (unclassified) Health Care Director, Director of Quality, Safety, & Infection Control position.

The University of Colorado Anschutz Medical Campus is a public education, clinical and research facility serving 4,500 students, and a world-class medical destination at the forefront of life-changing science, medicine, and healthcare. CU Anschutz offers more than 42 highly rated degree programs through 6 schools and colleges, and receives over $500 million in research awards each year. We are the single largest health professions education provider in Colorado, awarding nearly 1,450 degrees annually. Powered by our award-winning faculty, renowned researchers and a reputation for academic excellence, the CU Anschutz Medical Campus drives innovation from the classroom to the laboratory to the delivery of unparalleled patient care. Read CU Anschutz Quick Facts here.

 Nature of Work 

Jobs in this career family are responsible for performing a wide range of professional duties to support the university's teaching, research and/or service missions through the provision of health and wellness services,  dealing with general, indirect patient care operations and management of healthcare services.  Functions include hospital administration, healthcare regulatory compliance, patient relations, operational services, admissions, and medical records. Includes professional assignments in medicine, dentistry, nursing, pharmacy, counseling and behavioral health, public health, dietetics and nutrition, other allied health fields, alternative medicine and therapies, and related disciplines.

Directors are responsible for the ongoing leadership and oversight of a department, including the development of strategies and processes which contribute to the University and/or campus mission and accountability for services provided.  Directors are responsible and accountable for the analysis of fiscal and human resources required to achieve department objectives including hiring, compensation, termination, and performance management of subordinate employees.   

Under direction of the Associate Dean of the Division of Community Practice, the Director of Quality, Safety, & Infection Control will develop the vision and direction for the quality, performance improvement, infection control, and safety of patient care delivered by all CU School of Medicine practices. This position is responsible to develop programs to ensure compliance with federal and state regulatory (Colorado Department of Health, APIC OSHA, CDC, CMS, federal regulatory agencies) and licensure requirements, as well as establish organizational policies and procedures.

Duties and Responsibilities:

  • Strategic planning
  • Ability to plan and build a professional, effective team
  • Complex project management
  • Oversee and manage complex data collection, evaluation, management, and analysis.
  • Analyze and select appropriate data and analytics to present to the department/division.
  • Current knowledge and understanding of national and state legal and regulatory requirements.
  • Prepare MS Word, PowerPoint, Excel and Visio flow diagrams as needed for presentations to senior leaders.
  • Evaluate, monitor and recommend adjustments to billing.  Prevent financial losses by early identification and management of quality, safety, or infection control issues.
  • Administrative oversight and management of Quality, Safety, Infection Control, Patient Experience, and Bioengineering areas
  • Direct and oversee all human resources related functions to include, but not limited to, talent acquisition, performance management, and professional development for teams
  • In conjunction with Risk Management, this position develops and oversees comprehensive annual practice risk assessments for new and existing SOM practices to identify gaps in clinical and regulatory processes (including but not limited to OSHA, CLIA, laser safety, radiation safety infection prevention, sterilization, emergency operations, and facility management).  Oversees quality and action plans for all practices, including those that have identified gaps in process and opportunities for improvement.
  • Oversees health care facilities to provide and support safe and accessible buildings including parking, environmental services, security, etc.  Participates in facility contracting in order to identify potential quality and/or life safety issues.
  • Responsible for preventative education and training programs for OSHA mandates (workplace violence, inclement weather response, fire, emergency and active shooter drills).
  • Oversees hazardous waste materials management program including disposing of pharmaceuticals. Ensures appropriate and adequate protective equipment is provided and utilized by employees of all practices.
  • Makes regulatory, quality, safety and inflection control recommendations regarding construction and renovation projects.  Accountable for environmental rounds and compliance with national, state, local, and/or professional standards (e.g. fire doors, ventilation, gases, cleaning, infection control).
  • Oversees development, implementation, and supervision of  comprehensive radiation and laser safety programs.  Responsible for records of education and competency of faculty and staff.  Ensures the development of educational tools available for staff, providers and patients. Ensures appropriate protective equipment for radiology and laser utilization.
  • Oversees and participates in the establishment, implementation, and administration of infection control and sterilization policies and procedures; conducts or ensures ongoing review of policies, procedures and guidelines to identify infection control discrepancies and recommends/implements revisions as necessary. Ensures distribution of information to department managers to formulate action plans to meet the requirements in the policies, procedures.
  • Responsible for overseeing compliance of the Exposure Control Plan and Infection Control Practices of the division utilizing the national standards/guidelines of the Centers for Disease Control and Prevention (CDC).
  • Ensures full and accurate health and safety and training records are maintained. Provides reports including data and results to the senior management team on relevant health and safety activities including possible risks in processes, procedures, devices.
  • Serves as an expert resource on regulatory issues to the team, clinic staff, physicians, and leadership.
  • Directs bioengineering regarding assets and preventative maintenance, ongoing repairs and evaluation for lifespan of equipment.   Reviews products, equipment prior to purchasing for maintenance contracting.  Provides annual report to senior leadership regarding work orders, response time, equipment expenses and replacement recommendations.
  • Manages all equipment, product and medication recalls. Develops communication plan and back-up strategy for recalls.
  • Responsible for developing relationships with local security, emergency response and police agencies.  Oversees and standardizes security access control of all buildings.  Routinely conducts emergency response drills.
  • Assumes a leadership role on the Policy and Procedure Committee.  In conjunction with clinical operations, reviews and makes recommendations/changes to clinical protocols at prescribed review cadence.
  • Maintains knowledge and current standards in all areas described above.
  • Resource for all providers, staff, and clinics.
This description is a summary only and is describing the general level of work being performed, it is not intended to be all-inclusive. The duties of this position may change from time to time and/or based on business need. We reserve the right to add or delete duties and responsibilities at the discretion of the supervisor and/or hiring authority.

Supervision Received

This position will report directly to the Associate Dean of Community Practice Medicine

Supervision Exercised 

Direct supervisory responsibility for Quality, Safety, Infection Control, Patient Experience, and Bioengineering professionals.

Salary and Benefits:

The salary range (or hiring range) for this position has been established at $99,454 to $167,084.  

The salary of the finalist(s) selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training.

The above salary range (or hiring range) represents the University’s good faith and reasonable estimate of the range of possible compensation at the time of posting.

This position is not eligible for overtime compensation.

Your total compensation goes beyond the number on your paycheck. The University of Colorado provides generous leave, health plans and retirement contributions that add to your bottom line.


Total Compensation Calculator:

Diversity and Equity:

The University will provide reasonable accommodations to applicants with disabilities throughout the employment application process. To request an accommodation pursuant to the Americans with Disabilities Act, please contact the Human Resources ADA Coordinator at [email protected].

The University of Colorado Denver | Anschutz Medical Campus is committed to recruiting and supporting a diverse student body, faculty and administrative staff. The university strives to promote a culture of inclusiveness, respect, communication and understanding. We encourage applications from women, ethnic minorities, persons with disabilities and all veterans. The University of Colorado is committed to diversity and equality in education and employment.

The University of Colorado Denver | Anschutz Medical Campus is dedicated to ensuring a safe and secure environment for our faculty, staff, students and visitors. To assist in achieving that goal, we conduct background investigations for all prospective employees.

Minimum Qualifications

  • Bachelor’s degree in healthcare related field required.
  • Experience in healthcare quality and safety management within hospital, academic or ambulatory setting
  • Five (5) years progressive leadership, management or clinical education experience in hospital or ambulatory setting environment
  • Certification in Infection Control (CIC) required or obtained within 6 months of employment
  • Colorado RN License or Licensure/Certification in a healthcare related profession.
Preferred Qualifications:

  • Master’s in Nursing or other healthcare related field
  • Completion of Association for Practitioners in Infection Control (APIC) training course or equivalent
  • Experience with using registry data and quality systems
  • Experience working in large, complex healthcare systems
  • 5+ years of management experience.
  • Certified Professional in Healthcare Quality (CPHQ), clinical Performance Measurement and Reporting (CPRM), or other Quality Certification
Knowledge Skills and Abilities

  • Visionary leader with proven ability to build and grow teams. 
  • Must have the ability to guide and mentor colleagues.
  • Robust understanding of ambulatory/clinic operations and translating operations to clinic compliance, clinical performance, key performance indicators (KPIs), Quality of Care initiatives, and ambulatory process improvements.
  • Knowledge and expertise Colorado Department of Health, OSHA, CDC, CMS and other county, state, and federal regulatory agencies
  • Ability/knowledge to answer quality/safety inquiries regarding staff and patient care issues (i.e., policies, procedures, consents, documentation, equipment, etc.).
  • Must have critical thinking skills to see the big picture, determine problems, understand fundamental parts of problems, and guide solutions.
  • Must have the ability to collaborate with a multitude of teams and respond to time-sensitive situations. 
  • Excellent organizational, interpersonal, communication, and systems-thinking skills.
  • Negotiation skills including both internal and external, including leadership, staff, medical staff, regulatory agencies, and the community.
  • Strong presentation skills and ability to create needed educational material.
  • Proficiency in MS Word, Outlook, PowerPoint required
  • Experience with electronic health records, EPIC preferred.

Job Category: Health Care
Primary Location: Aurora
Schedule: Full-time
Posting Date: Apr 2, 2021
Unposting Date: Ongoing




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Job No:
Posted: 4/3/2021
Application Due: 7/2/2021
Work Type: Full Time