Director of Quality, Ethics and Compliance

Job Summary

Responsible for planning, implementing, and overseeing the hospital-wide performance improvement program to meet organizational and regulatory requirements. Provides education to medical staff, hospital staff, and the Governing Body while facilitating continuous quality improvement (CQI) activities across the organization. Serves as a key resource to the administrative team, department managers, and medical staff, and performs clinical risk management functions. Maintains oversight of regulatory surveys and all performance improvement activities. Acts as the Facility Ethics & Compliance Officer, ensuring adherence to organizational policies, regulatory standards, and ethical practices.

Essential Functions

• Plans, implements, and oversees the hospital-wide performance improvement program.
• Facilitates performance improvement and CQI initiatives across all departments.
• Collaborates with clinical leaders, department managers, administrative team, and Governing Body to support quality initiatives.
• Maintains current knowledge of regulatory requirements, accreditation standards, and industry best practices.
• Oversees preparation for regulatory surveys including Joint Commission, State Licensing, and CMS validation reviews.
• Educates and supports department managers in maintaining compliant policies and procedures.
• Utilizes database systems to document occurrences, track medical staff review activities, and compile reports for committees and leadership.
• Participates in and supports risk management and patient safety initiatives.
• Provides support to medical staff officers, committee chairpersons, and Governing Body as needed.
• Serves as the Facility Ethics & Compliance Officer and primary liaison to the Regional Compliance Director.
• Serves as the point of contact for workforce members regarding compliance-related questions and concerns.
• Escalates compliance issues appropriately and participates in regular compliance reviews.
• Prepares and submits quarterly compliance reports to facility and regional leadership.
• Maintains effective working relationships across departments to support patient care and organizational goals.
• Performs other duties as assigned.

Knowledge, Skills, and Abilities

• Excellent verbal, written, and interpersonal communication skills.
• Strong knowledge of accreditation standards, regulatory requirements, and healthcare compliance practices.
• Demonstrated critical thinking, prioritization, and problem-solving abilities.
• Able to manage multiple initiatives in a fast-paced environment.
• Proficiency in Microsoft Office applications, including Word and Excel.
• Able to work effectively under pressure and respond to urgent situations.
• Knowledge of federal, state, and local healthcare regulations.
• Able to collaborate effectively with interdisciplinary teams.
• Able to read, write, and speak fluent English.

Qualifications

• Education: Bachelor’s Degree in a healthcare-related field. (Required)
• Bachelor’s Degree in Nursing. (Preferred)
• Licenses/Certifications: Registered Nurse (RN) – State Licensure and/or Compact State Licensure in the state of practice. (Preferred upon hire)
• Certified Professional in Healthcare Quality (CPHQ). (Preferred upon hire)
• Experience: Three (3) or more years of experience in Quality and/or Risk Management in a hospital setting. (Required)