Director of Quality

Director of Quality

Hornell, NY (

Job Type

Full-time

Description

Job Title: Quality Director

Department:Quality

Reports To:Chief Medical Officer / Chief Nursing Officer

Job Type:Full-Time

Job Summary

TheDirector of Qualityis responsible for the leadership, development, and oversight of hospital’s quality, patient safety, and regulatory compliance programs. This role ensures alignment with accreditation standards, including The Joint Commission, and drives performance improvement initiatives across the organization. The Director of Quality oversees the Infection Prevention program and works collaboratively with clinical and administrative leaders to promote a culture of safety, accountability, and continuous improvement.

Key Responsibilities:Quality & Performance Improvement

• Lead the hospital-wide Quality Assessment and Performance Improvement (QAPI) program.

• Develop and implement hospital-widequality and patient safety programsaligned with regulatory and accreditation standards (e.g., The Joint Commission, CMS, OSHA).

• Utilizedata analytics and performance metricsto drive continuous quality improvement (CQI) initiatives.

• Oversee root cause analyses (RCAs), corrective action plans, and performance improvement activities.

• Report quality outcomes and trends to executive leadership and governing bodies.

• Chair and/or participate in key hospital committees related toquality, patient safety, and performance improvement.

Infection Prevention & Control Oversight

• Provide oversight and leadership to the Infection Preventionist and infection control program.

• Ensure compliance with infection prevention standards and evidence-based practices. Lead the hospital'sinfection prevention and control (IPC) program, ensuring adherence to CDC, WHO, and regulatory guidelines.

• Monitorhospital-acquired infections (HAIs)and implement strategies to reduce infection risks.

• Support education and initiatives to reduce infection risks across the organization.

Regulatory Compliance & Accreditation

• Ensure hospital compliance with all applicablestate, federal, and accreditation agencies, including CMS, The Joint Commission, and OSHA.

• Lead preparation for accreditation and regulatory surveys, audits, and inspections.

• Develop and maintain policies and procedures to align with evolving healthcare standards.

• Serve as the hospital’s primary resource for accreditation readiness and compliance.

Leadership & Collaboration

• Partner with medical staff, nursing, and department leaders to advance quality and patient safety goals.

• Chair or participate in quality and patient safety committees.

• Provide guidance and education on quality improvement methodologies and best practices.

• Foster a culture of accountability, transparency, and high reliability.

Requirements

Education & Experience

• Bachelor's Degree in Nursing (BSN), Healthcare Administration, or related field required;Master's Degree (MSN, MHA, MPH, or MBA) strongly preferred.

• Minimum of 5-7 years of progressive leadership experiencein hospital quality, case management, infection prevention, or related areas.

• Extensive experience inregulatory compliance, accreditation processes, and performance improvement methodologies (e.g., Lean, Six Sigma, PDSA cycles).

• Experience working withEHR systems, clinical analytics, and data-driven decision-making.

Certifications (Preferred/Required)

• Certified Professional in Healthcare Quality (CPHQ)

• Certified Case Manager (CCM) or Accredited Case Manager (ACM)

• Certified in Infection Control (CIC)

• Lean Six Sigma Green/Black Belt (preferred)

Skills & Competencies

• Strongleadership, communication, and collaborationskills.

• Expertise indata analysis, reporting, and quality improvement methodologies.

• Deep understanding ofregulatory and compliance standardsin healthcare.

• Ability to leadmultidisciplinary teamsand drive culture change.

• Strategic thinking with the ability to executehospital-wide initiativeseffectively.

Salary Description

$49.99-$61.30 per hour