Director, Quality

Job Description

Job Summary
The Director of Quality is responsible for leading and overseeing the facility’s quality improvement and patient safety programs. This role ensures compliance with regulatory and accreditation standards while fostering a culture of continuous improvement. The Director works closely with hospital leadership and clinical teams to monitor outcomes, drive performance improvement initiatives, and ensure delivery of safe, high-quality patient care.

• Lead the development and execution of quality and performance improvement strategies aligned with regulatory standards and organizational goals.
• Analyze quality metrics and clinical performance data to identify trends, prioritize opportunities, and drive improvements across departments.
• Guide and facilitate root cause analyses (RCA), Failure Modes and Effects Analysis (FMEA), and other quality methodologies.
• Partner with department leaders to implement corrective action plans, monitor progress, and meet performance benchmarks.
• Develop and deliver education on quality practices, patient safety, and regulatory updates to clinical and non-clinical staff.
• Ensure ongoing compliance with The Joint Commission, CMS, and other applicable regulatory and accrediting agencies.
• Present quality performance reports and improvement outcomes to executive leadership, hospital committees, and the Governing Board.
• Serve as a key resource for survey readiness and regulatory reporting.
• Perform additional duties as assigned and maintain adherence to organizational policies and standards.

Education:

• Bachelor’s degree in Nursing, Healthcare Administration, or a related field required
• Master’s degree preferred

Experience:

• 5–7 years of experience in healthcare quality, patient safety, or regulatory compliance
• Minimum of 1–3 years in a leadership role

• Strong knowledge of quality improvement methodologies, patient safety standards, and healthcare regulations
• Proven ability to analyze data and implement effective improvement strategies
• Excellent leadership, communication, and collaboration skills
• Proficiency in quality management systems and Google Workspace
• Ability to build cross-functional partnerships and lead change in a dynamic healthcare environment

Preferred:

• CPHQ – Certified Professional in Healthcare Quality
• CPHRM – Certified Professional in Healthcare Risk Management
   

What We Offer

• Competitive Pay
• Medical, Dental, Vision & Life Insurance
• Generous Paid Time Off (PTO)
• Extended Illness Bank (EIB)
• Matching 401(k)
• Opportunities for Career Advancement
• Rewards and Recognition Programs
• Additional Discounts and Perks*

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