Director of Quality Management

Purpose of Position

The Director of Quality Management serves as an integral part of the multidisciplinary team overseeing the department’s activities across the health care setting directing and managing the daily operations of the department. The director formulates and institutes effective strategies and policies that focus on the delivery of quality, cost-effective health care services. Ensures optimal utilization of resources and compliance with the operating standards of various health care governing and accrediting bodies, resulting in an improved patient experience.

Duties & Responsibilities

• Directs the overall day-to-day operations of the Quality Management Department’s activities following evidence-based guidelines and regulatory requirements and is accountable for the operational excellence and quality delivery of service across the health care setting.
• Designs, develops, and implements effective strategies and programs throughout the health care setting focused on improving quality, patient experience, and population health outcomes and reducing the cost of patient care.
• Partners with key stakeholders to define the strategic direction for the Quality Management Department’s initiatives, ensuring alignment with the System’s mission, values, and business goals.
• Maintains readiness for unannounced agency visits and participates in various regulatory agency surveys.
• Serves as regulatory liaison, specifically as it relates to departmental performance and the creation of action plans to assist leadership in communicating newly adopted approaches in reaching medical excellence.
• Investigates incidents involving patient care and safety, and makes reports to the appropriate public health and regulatory agencies.
• Prepares and/or actively participates in the development of the quality management fiscal year budget and allocation of funds.
• Ensures operations run within budgetary guidelines, reviews budget requests for quality management initiatives, identifies and meets staffing needs to support the continuity of care.

Minimum Qualifications

• Master’s degree from an accredited college or university in Quality Management, Hospital Administration, Health Care Administration, or in a related health care specialization; and five (5)years of experience in the development of organizational strategies and implementation of staffing plans, regulatory survey preparation and compliance, and in performance improvement and/or continuous quality improvement (CQI) initiatives in a hospital or health care setting, three (3) years of which must have been in a responsible administrative, managerial or supervisory capacity;
• Bachelor’s degree in the disciplines as described in “1” above; and seven (7) years of related experience, as listed in “1” above, five (5) years of which must have been in a responsible administrative, managerial or supervisory capacity;
• Bachelor’s degree in the disciplines as described in “1” above; and two (2) years of clinical, patient careor equivalent experience in a hospital or health care setting, plus three (3) years of related experience,as listed in “1” above, one (1) year of which must have been in a responsible administrative, managerialor supervisory capacity;
• A satisfactory equivalent of education, training, and/or experience.
• Certified Professional in Healthcare Quality (CPHQ) may be substituted for one (1) year of experience, however, all incumbents must have at least a bachelor’s degree and one (1) year of responsible administrative, managerial or supervisory experience, as described in “1” above.

Department Preferences

• Clinical education or experience strongly preferred.
• Strong knowledge of accreditation standards, healthcare regulations, and quality/performance improvement methodologies.
• Excellent analytical, critical thinking, and problem-solving skills with strong attention to detail.
• Effective communication and collaboration skills across interdisciplinary teams and all levels of staff.
• Ability to lead, mentor, and develop staff while fostering a culture of accountability, learning, and psychological safety.
• Strong leadership skills including delegation, facilitation, decision-making, and team coordination.
• Skilled in statistical analysis, data interpretation, and quality reporting for performance improvement initiatives.
• Able to prioritize and manage multiple complex projects in a fast-paced, high-pressure environment.
• Flexible, adaptable, and action-oriented with the ability to work independently and collaboratively.
• Integrity and professionalism in all interactions with staff, leadership, and external stakeholders.
• Strong conflict resolution skills with the ability to facilitate consensus and manage difficult situations effectively.
• Proficient in computer systems and software applications, including data analytics and reporting tools.