Director of Quality, Risk Management, Infection Prevention & Health

Director of Quality, Risk Management, Infection Prevention & Employee Health

Shift: (5) 8 hour day shift.

Salary Range: # - #8/Hr.

Placement Type:
Direct Hire

Reports to:

DON

Role Overview

The Director of Quality, Risk Management, Infection Prevention, and Employee Health is responsible for the development, implementation, oversight, and continuous improvement of CCMSD's Quality Assurance and Performance Improvement (QAPI) Program, Risk Management Program, Infection Prevention and Control Program, Employee Health Program, patient safety initiatives, and regulatory compliance activities. This position promotes a culture of safety, quality, accountability, and continuous improvement throughout the organization, including Acute Care, Long Term Care, Clinics, EMS, and ancillary departments.

The Director collaborates with leadership, providers, and staff to support compliance with applicable federal and state requirements and CCMSD policies.

· Direct and oversee the organization-wide Quality Assurance and Performance Improvement (QAPI) Program.

· Develop and monitor quality metrics, scorecards, dashboards, and performance indicators.

· Analyze and report quality outcomes, trends, and opportunities for improvement.

· Facilitate root cause analyses, performance improvement projects, and corrective action plans.

· Coordinate regulatory surveys, audits, and quality reviews.

· Lead quality committees and provide reports to executive leadership and the Board of Trustees.

· Promote evidence-based practices and continuous process improvement across all service lines.

· Monitor the effectiveness and sustainability of improvement initiatives.

· Direct the organization's Risk Management Program and patient safety activities.

· Coordinate review and investigation of patient, employee, visitor, and organizational incidents.

· Oversee event reporting, escalation, corrective actions, and follow-up processes.

· Conduct risk assessments and identify organizational vulnerabilities.

· Analyze adverse events, near misses, claims, grievances, and safety concerns.

· Collaborate with department leaders to develop and monitor risk mitigation strategies.

· Maintain organizational readiness for regulatory reviews and compliance inspections.

· Promote a culture focused on safety, accountability, transparency, and learning.

· Serve as the organizational lead for Infection Prevention and Control activities.

· Coordinate Annual Vaccinations for LTC residents.

· Maintain an active surveillance program to identify, investigate, prevent, and control healthcare-associated infections and communicable diseases.

· Monitor infection rates, trends, outbreaks, and epidemiological concerns.

· Oversee infection prevention policies, procedures, risk assessments, and annual program evaluations.

· Coordinate outbreak preparedness, response, recovery, and required reporting activities.

· Provide infection prevention education for staff, providers, volunteers, students, contractors, and other applicable personnel.

· Monitor hand hygiene, Standard and Transmission-Based Precautions, PPE use, isolation practices, and environmental infection prevention activities.

· Coordinate required reporting to NHSN and other applicable reporting systems.

· Provide consultation regarding infection prevention concerns.

· Direct and oversee the Employee Health Program.

· Manage employee immunization, tuberculosis screening, exposure management, and occupational health processes.

· Coordinate employee health surveillance and communicable disease monitoring.

· Assess or coordinate return-to-work eligibility and infectious disease exposure guidance.

· Support compliance with OSHA…