Director, Quality

Position Summary

Leads and oversees a comprehensive, efficient, and integrated hospital-wide Continuous Quality and Performance Improvement (CQPI) program. Uses data collection, analysis, and trending to assess performance; focuses on process and systems improvement; directs risk management and patient safety activities; investigates adverse outcomes; coordinates regulatory/accreditation readiness; and educates staff on CQPI and related quality programs.

Essential Functions

• Provide leadership and oversight of the organization-wide CQPI program.
• Measure and assess performance by collecting, analyzing, and trending data to identify opportunities for improvement.
• Focus on improving processes and systems to drive clinical quality, safety, and operational performance.
• Direct, facilitate, and report on all aspects of risk management and patient safety.
• Investigate factors contributing to adverse outcomes and drive process/system changes.
• Direct the hospital-wide CQPI operations, including record reviews for quality indicators and reporting findings to leadership, Medical Executive Committee, Board of Managers, and other committees.
• Annually review hospital-wide plans for Infection Control (IC) and CQPI; establish goals and objectives for the coming year.
• Serve as liaison to local health officials; coordinate inspections and accreditation reviews with state and other regulatory agencies.

Additional Information

• Develops and delivers hospital-wide CQPI education and training.
• Prepares quality/patient safety reports and dashboards for leaders and committees.
• Pairs with clinical and non-clinical departments to sustain improvements and ensure compliance with applicable standards.

Knowledge, Skills & Abilities

• Licensure: Registered Nurse with current state licensure highly preferred; clinical license required.
• Education: BSN or BS/BA required.
• Experience: Minimum two (2) years in an acute hospital or rehabilitation setting required; prior supervisory experience preferred.
• Certifications: Basic Life Support (BLS/CPR) required; certification preferred by APIC (American Practitioners of Infection Control) and NAHCQ (National Association of Health Care Quality).
• Skills: Data analysis and reporting; CQPI methodologies (e.g., RCA, FMEA, PDSA); risk management and patient safety facilitation; regulatory/accreditation readiness; effective teaching, communication, and collaboration.