Director of Quality, Compliance & Risk

Director of Quality, Compliance & Risk

Reports to:

Chief Executive Officer Status:
Exempt

Location:

Crook County Medical Services District

The Director of Quality, Compliance, & Risk provides strategic leadership and oversight for the organization's Quality Assurance and Performance Improvement (QAPI), regulatory compliance, enterprise risk management, and patient safety. This position promotes a culture of safety, accountability, continuous improvement, and organizational excellence across clinical and non-clinical departments. This Director position collaborates with executive leadership, medical staff, department leaders, and employees to maintain regulatory readiness, improve performance, strengthen workforce capabilities, and implement sustainable programs and services that meet organizational and community needs.

Essential Duties/Responsibilities:

Essential duties and requirements include the following. Other duties may be assigned:

Quality Improvement & Performance Excellence

• Direct and oversee the organization-wide QAPI program and related performance improvement activities.
• Establish, monitor, and report quality measures, patient safety indicators, benchmarks, dashboards, and organizational performance goals.
• Lead or coordinate performance improvement projects, root cause analyses, corrective action plans, and evaluation of sustained effectiveness.
• Analyze clinical, operational, patient experience, and financial data to identify trends, risks, and improvement opportunities.
• Prepare and present quality and performance reports to executive leadership, committees, medical staff, and the governing body as appropriate.
• Promote evidence-based practices, interdisciplinary participation, and a culture of continuous improvement.

Regulatory Compliance & Accreditation

• Lead the organizational compliance program and maintain readiness for regulatory, licensing, and accreditation surveys.
• Monitor applicable federal and state requirements, CMS Conditions of Participation, HIPAA, OSHA requirements, and other standards relevant to organizational operations.
• Coordinate compliance audits, mock surveys, documentation reviews, corrective actions, and follow-up monitoring.
• Oversee policy and procedure review, approval workflows, version control, and regulatory alignment.
• Maintain confidential reporting pathways and support non-retaliation, investigation, and corrective action processes.
• Provide compliance reports, education, and recommendations to leadership and governing bodies.

Risk Management & Patient Safety

• Direct the enterprise risk management and patient safety programs.
• Oversee incident, adverse event, near-miss, grievance, and safety concern reporting, investigation, trending, and follow-up.
• Conduct risk assessments and develop mitigation strategies for clinical, operational, environmental, privacy, and organizational risks.
• Promote Just Culture principles and employee participation in safety reporting and risk reduction.
• Coordinate required risk management program evaluations and monitor corrective actions for effectiveness.
• Collaborate with legal counsel, insurers, and organizational leaders as authorized regarding claims, liability, and risk concerns.

Data, Reporting & Governance

• Develop and maintain executive dashboards, scorecards, trend analyses, and reports for assigned programs.
• Ensure integrity, confidentiality, and appropriate use of quality, compliance, risk, training, and operational data.
• Chair, coordinate, or participate in quality, compliance, risk, education, and organizational development committees as assigned.
• Support strategic planning, annual program evaluations, policy governance, and reporting to executive leadership and the governing body.

Leadership & Supervision

• Serve as a…