Director of Quality, Risk, and Compliance (On Site )
Position Summary
The Director plays a critical role in cultivating a culture of patient safety, continuous improvement, and regulatory excellence to ensure the highest standards of care for the community. This position leads the organization’s quality, risk, and compliance programs, partnering closely with clinical and operational leaders to strengthen performance and drive measurable improvements in patient outcomes.
Essential Functions
Build Trust: Oversee patient complaints and grievance processes ensuring compliance, documentation, follow-up, service recovery, and improvement. Investigate and address incident reports resolving care issues and recommending prevention strategies. Ensure confidentiality of all quality-related data and provide accurate reports to the Board of Commissioners and leadership.
Respond to and prepare information for public record requests. Develop and direct strategies for Compliance including HIPAA investigations, auditing, the organizational Compliance plan, and serving in the Privacy Officer role.
Build and maintain strong relationships with stakeholders including patients, families, employees, and regulatory bodies. Ability to function under stressful situations maintaining professionalism and compassion during high-pressure events.
Obsess Over Excellence: Maintain and implement the District-wide Quality Plan ensuring alignment with regulatory standards and organizational goals. Develop and direct strategies for risk management including investigating incidents, training staff, and addressing legal concerns or actions. Assist department managers in identifying improvement opportunities aligned with annual District Quality Goals. Assist managers in event management review selecting effective corrective actions for safety issues. Oversee patient experience processes and metrics ensuring high-quality, consistent care. Serve as a resource for QI initiatives providing leadership, education, and guidance.
Lead Innovation: Lead efforts to educate staff on regulations and best practices fostering a learning culture that adapts to evolving standards. Facilitate and chair committees such as the Patient Safety and Quality Metrics Sub-Committee, driving innovative safety and performance strategies. Develop and direct forward-thinking strategies for compliance, risk management, and quality improvement. Integrate patient feedback creatively using surveys and data to shape new approaches to care. Manage and develop quality data reporting, both internal and external.
Deepen Connections: Oversee and manage Patient Relations ensuring compassionate, responsive communication. Assure the “voice of our customers” is incorporated through patient satisfaction surveys and care-related data. Build and maintain strong relationships with all stakeholders, strengthen trust and collaboration. Oversee patient experience processes ensuring patients and families feel heard, respected, and supported.
Qualifications
Education: Bachelor’s degree required in Professional clinical discipline, such as, but not limited to, Nursing, Occupational or Physical Therapy, Laboratory etc. Preferred: Advanced degree desirable in health care administration, quality management, adult learning, or other discipline with emphasis on outcomes assessment and data management.
Specialty Certification: Preferred: CPHQ, Certified Professional Healthcare Quality CPHRM, Certified Professional in Healthcare Risk Management
Experience: At least 5-years professional healthcare experience. At least 3-5-years’ experience in quality assurance, quality improvement, or risk management. Experience managing quality improvement activities such as process improvement, lean methodologies, quality system assessment. Experience interpreting healthcare regulations and accreditation requirements and designing systems to meet them. Experience with customer service and patient relations. Survey design as well as interpretation and communication of survey results. Proficiency in data management, statistical methods, and effective communication across all organizational levels.
Skills
Strong ability to maintain confidentiality, navigate complex situations, and express ideas effectively to groups. Experience utilizing EPIC EMR. Group facilitation skills required. Strong communication skills both written and verbal. Demonstration of strong strategic and change management leadership. Demonstrated ability to work with cross-functional teams to achieve organizational objectives. Ability to effectively interact with patients and families and deescalate stressful situations. Problem-solving and coaching in a team environment. Computer skills including Microsoft Word, Microsoft Excel, Microsoft Visio, and on-line database management.