Director Quality and Regulatory

Major Responsibilities

• Directs, organizes, and plans the site clinical and administrative functions of the ISO9001 Quality Management System, including Quality Management Oversight Committee, and its requirements.
• Monitors performance improvement activity in accordance with system and site safety and health outcomes priorities.
• Provides leadership and oversight to external agency visits, including accreditation and certification surveys, state surveys, and other agency investigations.
• Serves as the hospital management representative and preparation agent for DNV and ISO surveys.
• Manages and oversees the hospital physician and APC peer review program, including the provision of data and case review for OPPE and FPPE related processes.
• Oversees the hospital contract management program, including maintenance of a hospital log and overall evaluation.
• Manages the hospital document management program, including policies, procedures, scope of service, and other key site documents.
• Performs human resources responsibilities for staff, including interviewing and selection of new employees, promotions, staff development, performance evaluations, compensation changes, resolution of employee concerns, corrective actions, terminations, and overall employee morale.
• Develops and recommends operating and capital budgets and controls expenditures within approved budget objectives.
• Understands and adheres to the organization's Code of Ethical Conduct and ensures that personal actions, and the actions of employees supervised, comply with the policies, regulations, and laws applicable to the organization's business.

Licenses, Registrations and Certifications

Required: None

Education

Required: Bachelor’s degree in healthcare or related field.

Experience

Typically requires 7 years’ experience in quality improvement. Includes 3 years’ experience in leadership role.

Knowledge, Skills & Abilities

• Advanced knowledge of quality improvement methodologies (i.e. Lean, Six Sigma)
• Analytical and statistical skills
• Clinical knowledge of care processes
• Proficiency with MS Office
• Facilitation skills; excellent verbal and written communication skills
• Proficiency with change management
• Proficiency with project management

Physical Requirements and Working Conditions

• Ability to sit for extended periods of time.
• Ability to travel to other AAH locations.
• Exposed to normal office environment.
• Operates all equipment necessary to perform the duties of the job.