Director of Quality

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$92,000.00/yr - $97,000.00/yr

Manager/Director of Quality Management - Perm

The Director of Quality Management has responsibility for the quality program for a hospital facility. This includes developing and implementing patient safety initiatives, assuring the success of continuous quality enhancement initiatives inter‑and intra‑departmentally, developing a proactive risk management program, and overseeing an effective infection prevention and control and employee health program. This role is responsible for appropriately using quality tools (root cause analysis, failure mode effects analysis, statistical process control, and other statistical methods) to guide process improvement, help problem solve, and benchmark appropriately to ensure a highly reliable organization.

The Director ensures compliance with regulatory and accreditation standards and ensures they are continually upheld. The Director will be responsible for the planning, development, implementation, administration, evaluation, and continual enhancement of policies, procedures, and practices for each functional area. Other duties may be assigned as appropriate.

2-year associate degree with 5+ years of relevant experience in Quality, Risk or Infection Control

• 3-5 years of acute care/hospital experience
• 1 year of Quality experience; prior Director of Quality Management or equivalent is preferred

• Must have an active clinical license such as RN or RT
• CIHQ IC or CIQH-HACP-CMS certification or equivalent OR commitment to obtain certification within 2 years

• Works with medical staff and administration to ensure compliance with regulatory agencies
• Manages all clinical quality outcome and performance improvement functions
• Creates and distributes agendas, minutes and quarterly reports related to quality
• Coordinates data collection for studies and management reports
• Analyzes study results in collaboration with Medical Staff to develop follow‑up monitoring, and problem‑solving actions
• Communicates findings through designated reporting and committee structures
• Ensures follow‑up on actions and recommendations made by committees
• Performs investigations and root cause analysis
• Consults and provides input into policy, procedures and standards
• Develops and delivers educational seminars related to performance improvement
• Supervises ongoing and annual program reviews

• Coordinates all patient safety and risk management activities, including developing and implementing policies and procedures, education, and communication
• Manages Risk Committee meetings and activities
• Manages the hospital Patient Safety Risk Program, including education, reporting, and evaluation of effectiveness

• Plans, develops, implements, and manages the Infection Prevention and Control program
• Coordinates surveillance, recording, investigation, and reporting of data for hospital‑associated and community‑acquired infections, including admission reviews
• Coordinates concurrent review of nosocomial trends
• Notifies Public Health agency of any reportable disease cases
• Notifies administration and medical staff of unusual infection control situations
• Attends P&T/IC committee meetings, preparing agendas, minutes and providing informational updates to committee members on a timely basis
• Provides staff education, orientation and annual recertifications

• Manages Employee Health Plan and activities
• Ensures appropriate vaccination status and/or declination documents are accurately maintained
• Reviews / clears employees who have been out on sick leave return to work documentation / fitness for duty assessments

• Quality and performance improvement techniques
• Investigation / Root cause analysis skills
• Operational knowledge of an acute‑care hospital
• Regulatory awareness
• Communication (written and oral) & interpersonal skills

#IND
103

Director

Full‑time

Health Care Provider

Hospitals and Health Care

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