Director OF Quality

Director of Quality / RiskThe Director of Quality / Risk is responsible for leading and governing the organization's quality improvement, patient safety, regulatory compliance, and risk management programs across all departments. This role partners with executive leadership, medical staff, and the Board to ensure high-quality patient care, regulatory readiness, and continuous performance improvement while minimizing organizational risk and liability.Reporting StructureReports To: Administration / Executive LeadershipSupervises: Quality Staff and Clinical EducatorMust-Have RequirementsMaster's degree in Nursing or related healthcare fieldActive RN (Registered Nurse) license (Iowa or eligible)Minimum 5+ years of leadership/management experience in: Quality ImprovementRisk ManagementNursing / Healthcare OperationsKey ResponsibilitiesQuality / Performance Improvement / AccreditationLead organization-wide Quality & Performance Improvement programsServe as Patient Safety OfficerDrive regulatory compliance and accreditation readiness (Joint Commission, CMS, etc.)Lead external audits, surveys, and mock inspectionsDevelop and present quality metrics and performance reportsOversee infection prevention and control programsManage incident reporting systems and quality data analyticsConduct Root Cause Analysis (RCA) and performance improvement initiativesCollaborate with leadership to improve patient outcomes and care qualityRisk ManagementLead enterprise risk management strategy and executionIdentify, analyze, and mitigate clinical and operational risksOversee incident investigations, claims management, and liability exposureDevelop and maintain Risk Management Plan and annual reportsEnsure compliance with state, federal, and regulatory requirementsManage patient complaints, grievance handling, and service recoverySupport legal processes including claims, litigation, and documentationConduct FMEA, RCA, and Sentinel Event investigationsLeadership & CollaborationEngage with medical staff, leadership teams, and Board of DirectorsLead quality committees and cross-functional initiativesMentor and develop staff within quality and risk functionsPromote a strong culture of safety and continuous improvementPreferred QualificationsCertification in Patient Safety (CPPS) (required within 1 year of hire)CPHQ (Certified Professional in Healthcare Quality) preferredExperience in Joint Commission and CMS regulationsExperience in hospital or acute care environmentCore SkillsHealthcare Quality & Performance ImprovementRisk Management & Patient SafetyRegulatory Compliance (CMS, Joint Commission, OSHA, etc.)Root Cause Analysis (RCA), FMEAData Analysis & ReportingLeadership & Stakeholder ManagementClinical Operations KnowledgeKnowledge, Skills & AbilitiesStrong understanding of healthcare regulations and accreditation standardsExcellent communication, leadership, and presentation skillsAbility to lead organization-wide quality and risk initiativesStrong analytical and problem-solving capabilitiesHigh level of confidentiality and compliance awarenessEducation & CertificationsMaster's degree (required)RN License (required)CPPS (within 1 year)CPHQ (preferred)Additional InformationLeadership role with direct impact on patient safety and care qualityHigh visibility with executive leadership and BoardFocus on continuous improvement and regulatory excellence