Director of Quality Management

Role Overview

The Director of Quality Management leads the hospital’s quality, patient safety, accreditation readiness, and regulatory compliance efforts. This position is responsible for building and maintaining an integrated quality program aligned with the organization’s Quality Improvement and Patient Safety Plan.

Key Responsibilities

• Design, launch, track, and improve the hospital’s integrated quality program.
• Run the Continuous Quality Improvement Committee and related initiatives.
• Lead and oversee the Medical Staff and Quality Team.
• Partner with managers and medical staff to select quality measures, monitor performance, audit processes, and document findings, conclusions, and corrective actions.
• Manage the peer review workflow, including OPPE and FPPE processes for MEC operations.
• Prepare and provide data and reports needed for physician/LIP credentialing and peer review.
• Support medical record review based on screening criteria chosen by the medical staff and assemble record excerpts for committee review.
• Oversee the Performance Improvement program.
• Lead patient safety efforts and connect them with quality improvement work to ensure continuity across programs.
• Ensure adverse events are reported to outside agencies when required.
• Take part in safety and environment-of-care rounds, accreditation survey preparation, and follow-up corrective actions for identified gaps.
• Direct accreditation and hospital licensure activities and maintain consistency across all related workstreams.
• Build and sustain professional relationships with internal teams, outside organizations, and the community.
• Deliver service in a way that supports the patient’s age-specific physical, psychosocial, educational, and safety needs.
• Maintain a courteous, professional, and helpful approach with patients, visitors, employees, medical staff, and others.
• Stay current on statutes, regulations, standards, and policies needed to carry out the role in line with the Corporate Compliance Plan.
• Follow the Code of Conduct, Corporate Compliance Plan, and compliance policies and procedures, including required training.
• Support compliance activities as directed by the Corporate Compliance Officer.
• Ensure regulatory compliance for all state and federal agencies affecting hospital and ASC Medical Staff Services.
• Plan, design, implement, modify, integrate, and evaluate accreditation-readiness program components so compliance becomes part of daily work.
• Perform other assigned duties as needed.

Qualifications

• Bachelor’s degree in health/public health administration, business administration, nursing, or a closely related field; a master’s degree is preferred.
• At least 3 years of progressively responsible experience in quality improvement management or nursing quality management.
• CPHQ or an equivalent certification is preferred.
• Strong working understanding of healthcare delivery principles and theories.
• Deep familiarity with accrediting standards, regulatory requirements, and licensing processes, including The Joint Commission, CMS, and other agencies.
• Strong grasp of organizational theory, management methods, and related principles.
• Excellent communication skills and a consistently professional demeanor.
• Thorough knowledge of OPPE and FPPE, with responsibility for overseeing all OPPE/FPPE evaluations.
• Proficiency with Epic and Microsoft Office tools, including Word, Excel, Outlook, and PowerPoint.
• Education requirement also notes a bachelor’s degree in nursing.
• Experience requirement also states 2 years in acute care hospital quality, regulatory, and risk management.

Work Environment & Exposure

This role is based in an office setting. The position includes Category II exposure to blood-borne pathogens, frequent contact with chemical hazards, and possible exposure to radiation hazards.

Physical Requirements

• Frequent sitting, speaking, listening, and use of hands and arms to handle or manipulate objects and controls.
• Close vision and the ability to adjust focus are required.
• Must be able to lift and/or carry more than 20 pounds regularly.
• Must be able to push and/or pull more than 25 pounds regularly.
• Must be able to stand and/or walk for at least 5 hours per day.
• Reasonable accommodation may be available for individuals with disabilities.

Equal Opportunity Notice

The employer states that applicants are entitled to federal employment law rights and can review the Department of Labor’s Know Your Rights notice for more information.