Director, Quality

Director of 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. Perform other duties as assigned. Additional Information Develops and delivers hospital-wide CQPI education and training. Prepares quality/patient safety reports and dashboards for leaders and committees. Partners 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. #J-18808-Ljbffr