Director of Quality - RN

Director of Quality (RN)

Nexus Children's Hospital – Shenandoah is a specialty pediatric hospital serving children and adolescents with complex medical, behavioral, neurological, and neurodevelopmental conditions. Our interdisciplinary programs provide highly specialized inpatient care focused on improving patient outcomes, safety, and quality of life through compassionate, evidence-based treatment.

We are committed to clinical excellence, innovation, patient safety, and fostering a culture of accountability and continuous improvement across all levels of care.

The Director of Quality (RN) provides facility-level leadership and operational oversight of the Quality, Patient Safety, Risk Management, Patient Experience, and Performance Improvement programs for a specialty hospital system serving patients with neurodevelopmental disorders and complex behavioral and medical conditions.

This role ensures alignment of facility quality practices with corporate strategy, regulatory requirements, accreditation standards, and organizational goals while driving local execution, operational reliability, and sustained improvement in patient outcomes. The Director of Quality serves as the primary liaison between corporate quality leadership and facility operations to ensure consistent implementation of quality initiatives, compliance standards, and performance expectations.

Quality Leadership & Performance Improvement

• Leads facility-wide Quality Assurance and Performance Improvement (QAPI) initiatives to improve clinical outcomes, patient safety, and care reliability.
• Directs implementation of evidence-based practices and standardized clinical processes across all care settings.
• Monitors, analyzes, and trends clinical quality indicators, adverse events, patient outcomes, and operational metrics.
• Oversees development and utilization of quality dashboards, scorecards, KPI reporting, and performance metrics.
• Facilitates interdisciplinary collaboration between nursing, behavioral health, medical, therapy, and operational leadership teams.
• Promotes a culture of safety, transparency, accountability, and high-reliability care delivery throughout the organization.
• Evaluates the effectiveness of quality initiatives and escalates risks appropriately.

Regulatory Compliance & Accreditation

• Ensures ongoing compliance with CMS, DNV, Joint Commission, HIPAA, and applicable state and federal regulations.
• Leads all accreditation and regulatory survey activities including preparation, onsite coordination, mock surveys, gap assessments, and corrective action planning.
• Oversees investigation, reporting, and mitigation of adverse events, near misses, and sentinel events.
• Directs Root Cause Analyses (RCA), Failure Mode and Effects Analyses (FMEA), and other structured risk assessments.
• Partners with Risk Management, Legal, and operational leadership to reduce regulatory and organizational risk exposure.
• Oversees internal audits, clinical documentation reviews, tracer methodology, and compliance monitoring activities.
• Provides regular reporting to executive leadership and governing bodies regarding quality performance, regulatory readiness, and organizational risk.

Patient Safety & Patient Experience

• Provides leadership oversight for patient advocacy and patient experience initiatives.
• Ensures systems are in place to protect patient rights, dignity, autonomy, and informed participation in care.
• Oversees grievance, complaint, and allegation processes to ensure timely investigation and resolution.
• Promotes trauma-informed, patient-centered, and developmentally appropriate care practices.
• Monitors patient experience trends and collaborates with leadership to improve communication, safety, and care coordination.
• Ensures appropriate reporting and escalation of high-risk concerns including abuse, neglect, exploitation, and rights violations.

Operational & Organizational Leadership

• Serves as the facility's primary quality liaison between hospital leadership and corporate quality teams.
• Supports integration of quality, compliance, and patient safety initiatives into daily operations.
• Collaborates with facility leadership to improve operational efficiency, workflow reliability, and patient outcomes.
• Develops and supports staff education related to patient safety, quality improvement, compliance, and regulatory readiness.
• Maintains current knowledge of healthcare quality trends, accreditation standards, and patient safety best practices.
• Promotes professional development and competency validation for quality and patient safety initiatives.
• Performs additional duties as assigned.

Education

• Bachelor's Degree in Nursing from an accredited school of nursing required.
• Master's Degree in Nursing (MSN), Healthcare Administration (MHA), Public Health (MPH), or related healthcare field required.

Experience

Required

• Minimum 7–10 years of progressive clinical and quality leadership experience in healthcare.
• Minimum 3–5 years in a leadership role involving quality, patient safety, risk management, or performance improvement.
• Demonstrated experience with:
  • Regulatory surveys and accreditation processes (CMS, DNV, Joint Commission, or equivalent)
  • QAPI programs and performance improvement initiatives
  • Incident management, root cause analysis, and risk mitigation strategies

Preferred

• Experience in behavioral health, neurodevelopmental populations, specialty hospitals, or complex care environments.
• Experience within multi-site or system-based healthcare organizations.

Skills & Competencies

Quality & Clinical Leadership

• Strong knowledge of healthcare quality, patient safety, regulatory compliance, and accreditation standards.
• Expertise in performance improvement methodologies, clinical outcomes management, and risk mitigation.
• Ability to lead interdisciplinary teams and influence operational and clinical stakeholders.

Operational & Analytical Skills

• Strong analytical, critical thinking, and problem-solving abilities.
• Experience developing and utilizing dashboards, scorecards, and quality metrics.
• Ability to analyze complex clinical and operational data and translate findings into actionable improvement strategies.

Technology & Reporting

• Advanced proficiency in Microsoft Office Suite, including Excel, PowerPoint, and Word.
• Experience with data visualization tools such as Power BI preferred.
• Proficiency with Electronic Health Record (EHR) systems and quality reporting functionality.

Leadership & Change Management

• Excellent communication and presentation skills.
• Demonstrated ability to lead organizational change and foster a culture of accountability and continuous improvement.
• Ability to manage complex, high-risk operational and clinical situations effectively.

Licensure & Certification

• Active, unrestricted Registered Nurse (RN) license required.
• Current BLS certification through the American Heart Association or American Red Cross required.
• De-escalation training required within 30 days of hire.
• Professional certification such as CPHQ, CPPS, or Lean Six Sigma preferred.

Why Join Nexus Children's Hospital – Shenandoah?

• Opportunity to lead transformational quality and patient safety initiatives
• Collaborative executive leadership environment
• Meaningful work serving medically and behaviorally complex pediatric populations
• Mission-driven organization focused on clinical excellence and innovation
• Competitive compensation and comprehensive benefits package

Join a team dedicated to improving lives through compassionate care, operational excellence, and continuous improvement.