System Director Surgical Safety

Inspired by faith. Driven by innovation. Powered by humankindness. CommonSpirit Health is building a healthier future for all through its integrated health services. As one of the nation’s largest nonprofit Catholic healthcare organizations, CommonSpirit Health delivers more than 20 million patient encounters annually through more than 2,300 clinics, care sites and 137 hospital-based locations, in addition to its home-based services and virtual care offerings. CommonSpirit has more than 157,000 employees, 45,000 nurses and 25,000 physicians and advanced practice providers across 24 states and contributes more than $4.2 billion annually in charity care, community benefits and unreimbursed government programs. Together with our patients, physicians, partners, and communities, we are creating a more just, equitable, and innovative healthcare delivery system.

The System Director for Surgical Safety is responsible for leading, directing and supporting surgical safety initiatives that reduce harm, improve outcomes, and promote a culture of high reliability within the surgical and perioperative environment. This role ensures adherence to evidence-based practices, national safety standards, and regulatory requirements to minimize risks during surgical procedures. This System Director role collaborates across disciplines including surgery, anesthesia, nursing, sterile processing, and quality teams to identify gaps and implement system-wide improvements in surgical care.

Essential Function

• Lead and direct the implementation and oversight of surgical safety programs (e.g., Surgical Safety Checklist, Time-Outs, Universal Protocol).
• Provide real-time support during surveys related to surgical processes, documentation, and safety practices.
• Analyze surgical safety data, trends, and outcomes; partner with hospital teams to drive continuous improvement.
• Maintain system consistency in policies, procedures, and evidence-based standards for surgical safety.
• Collaborate with patient safety, quality, regulatory readiness, and OR leadership teams to track and address high-risk areas.
• Serve as a resource and subject matter expert for interpreting regulatory CoPs and standards during surgical safety-focused survey activities.

The job summary and responsibilities listed above are designed to indicate the general nature of the work performed within this job. They are not designed to contain or be interpreted as a comprehensive inventory of all job responsibilities required of employees assigned to this job. Employees may be required to perform other duties as assigned.

Experience

• A minimum of seven (7) years of experience in the discipline with progressive management responsibility in a health care setting/system, five (5) years of leadership experience related to managing Surgical Operations in an acute care organization. Experience driving surgical safety initiatives and quality improvement in a multi-site health system

Education - Licensure and Certifications

• Bachelors of Nursing 
• Master's Preferred
• RN Licensed

Preferred

• Certified Nurse Operating Room (CNOR)