St. Agnes Medical Center - Fresno, CA

Director of Quality, Safety, Accreditation & Risk

Job Summary

Director of Quality, Safety, Accreditation & Risk

We are looking for a registered nurse to step into the role of Director of Quality Management at Lourdes Health in Pasco, Washington. You will manage the operational, financial, and personnel resources for the Quality Department at the critical access hospital and the psych hospital, and will report directly to the Chief Nursing Officer.

You will be required to have an RN license and a Bachelor’s degree, along with 5 years of comparable experience and a minimum of 3 years at a leadership level. An ideal candidate will have their CPHQ or CPHRM certification or is Bilingual with English and Spanish. 

St. agnes medical center

Lourdes Health Network is a Catholic health care institution, focused on serving their community with respect, compassion, and care. A 35 bed critical access hospital, Lourdes Medical Center has been awarded a five-star Overall Hospital Quality rating in 2021 and is only one of seven hospitals in Washington State to earn five stars and 455 throughout the country, putting Lourdes Health in the top 14% of all hospitals.

About the town

fresno, CA


Public Schools




Good for Familes




Cost of Living


Outdoor Activities


Crime & Safety








Health & Fitness



Leapfrog Hospital Safety Scores

st. agnes 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?0.0000.3520.0150.000CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
Air or gas bubble in the blood What’s This?0.0000.3580.0010.000CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
Patient falls and injuries What’s This?0.5482.2290.4370.000CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
Infection in the blood What’s This?1.9204.4621.0770.0002022 Leapfrog Hospital Survey07/01/2021 – 06/30/2022
Infection in the urinary tract What’s This?1.2173.5160.8620.0002022 Leapfrog Hospital Survey07/01/2021 – 06/30/2022
Surgical site infection after colon surgery What’s This?0.8473.1170.8220.0002022 Leapfrog Hospital Survey07/01/2021 – 06/30/2022
MRSA Infection What’s This?1.5833.9181.0950.0002022 Leapfrog Hospital Survey07/01/2021 – 06/30/2022
C. diff. Infection What’s This?0.4322.0660.4890.0002022 Leapfrog Hospital Survey07/01/2021 – 06/30/2022
Death from treatable serious complications What’s This?164.78186.71143.2373.88CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
Harmful Events What’s This?0.852.700.980.50CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
      Dangerous bed sores What’s This? *0.419.620.590.01CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
      Collapsed lung What’s This? *0.130.390.190.08CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
      Falls causing broken hips What’s This? *0.080.330.080.01CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
      Blood Leakage What’s This? *2.154.732.381.29CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
      Kidney injury after surgery What’s This? *0.943.060.920.27CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
      Serious breathing problem What’s This? *5.2546.916.731.15CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
      Dangerous blood clot What’s This? *3.647.743.401.11CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
      Sepsis infection after surgery What’s This? *4.218.704.151.53CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
      Surgical wound splits open What’s This? *0.641.980.810.30CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
      Accidental cuts and tears What’s This? *0.553.131.040.32CMS07/01/2019 – 12/31/2019 and 07/01/2020 – 06/30/2021
* 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?701591.771002022 Leapfrog Hospital Survey2022
Safe medication administration What’s This?752591.221002022 Leapfrog Hospital Survey2022
Specially trained doctors care for ICU patients What’s This?100567.471002022 Leapfrog Hospital Survey2022
Effective leadership to prevent errors What’s This?120.009.23116.86120.002022 Leapfrog Hospital Survey2022
Staff work together to prevent errors What’s This?120.000.00115.87120.002022 Leapfrog Hospital Survey2022
Enough qualified nurses What’s This?100.000.0098.13100.002022 Leapfrog Hospital Survey2022
Handwashing What’s This?401571.641002022 Leapfrog Hospital Survey2022
Communication with nurses What’s This?847589.8197CMS04/01/2021 – 03/31/2022
Communication with doctors What’s This?857689.7097CMS04/01/2021 – 03/31/2022
Responsiveness of hospital staff What’s This?765881.3094CMS04/01/2021 – 03/31/2022
Communication about medicines What’s This?704874.2187CMS04/01/2021 – 03/31/2022
Communication about discharge What’s This?826185.0795CMS04/01/2021 – 03/31/2022

Hospital Leadership

MEET THE staff

Michael F. Trevisani

Interim Chief Medical Officer

Fran Petersen

Infection Control Practitioner

Official job description

st. agnes medical center- Director of Quality, Safety, Accreditation & Risk

Reporting to the Chief Medical Officer, Executive Management, this position has oversight responsibility for the Quality Resources Department, Safety, Accreditation, Risk Management, Infection Control and Prevention. This position directs the development of strategic quality and safety initiatives that are aligned with organizational objectives and works collaboratively with hospital leaders and medical staff to advance the quality and safety agenda at the organization.

The director is responsible for promoting a de-centralized model for continuous survey readiness, collaborating with other members of the Accreditation team in development of a functional team infrastructure that supports individual accountability for compliance with The Joint Commission (TJC) and Center for Medicare & Medicaid Services (CMS) standards.

As Risk Manager for Saint Agnes Medical Center, this position is responsible for managing and coordinating risk management and clinical patient safety. The incumbent serves as liaison to the California Department of Public Health (CDPH) and other pertinent regulatory agencies. This position maintains a liaison reporting relationship to Trinity Risk Management Services and serves as a member of the Trinity Risk Management Council.
1.Bachelor’s Degree in Health Administration, Nursing, Business or a related field is required. Master’s degree is preferred.
2.Five (5) years’ experience in a leadership role or managerial function is required.
3.Progressive experience in quality management and clinical process improvement is required
4.Current licensure as a Registered Nurse in the State of California is required.
5.Certified Professional in Healthcare Quality (CPHQ) issued by National Association for Healthcare Quality (NAHQ) is required.
6.Knowledge of Joint Commission Accreditation standards, CMS’ Conditions of Participation and Title XXII regulations is required.
7.Special skills including well developed leadership ability, strong interpersonal and written communication skills, project management, and team-building expertise are required.

Our Commitment to Diversity and Inclusion:
Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

Like what you've seen?

Would you like to
proceed with presentation?


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

meet our recruitment team

Scroll to Top