Hospital Director of Quality and Risk

Job Details / Responsibilities

Lead all quality, risk management, and patient safety initiatives including performance improvement activities

Serve as the primary leader for State, Joint Commission, and CARF surveys, developing responses and action plans

Manage patient experience and satisfaction processes, including NRC/Press Ganey surveys, handling complaints, and the grievance letter process

Oversee regulatory compliance, conflict resolution, and risk management activities

Work hands-on alongside facility staff, patients, and leaders to drive quality outcomes

Supervise and support 1 Patient Assessment Standards Coordinator (PASC)

Collaborate directly with the hospital CEO and Regional Director of Quality and Risk

Implement LEAN/Six Sigma principles where applicable to enhance processes

Qualifications

• Minimum 2+ years in leadership roles with demonstrated stability (short tenures not preferred)
• Significant experience in Risk Management, Quality, and Patient Safety with primary responsibility for performance improvement and regulatory compliance
• Hands-on experience leading State, Joint Commission, or CARF surveys and creating action plans
• Experience with Patient Experience/Patient Satisfaction surveys (NRC or Press Ganey) and grievance processes
• Proven track record working onsite alongside clinical staff, patients, and facility leaders (corporate-only or remote-only backgrounds not suitable)
• Clinical licensure highly preferred but not required
• LEAN/Six Sigma training or certifications (Yellow/Green/Black Belt) strongly preferred