Quality Director

About This Role

This role focuses on planning, developing, implementing, and managing comprehensive systems to monitor and evaluate the quality and appropriateness of patient services and programs. The Director works closely with the Hospital CEO to coordinate administrative processes efficiently and cost-effectively, ensuring compliance with regulatory standards and organizational goals.

Responsibilities

• Work with the VP, Quality and Patient Safety, implementing organization-wide quality programs at the hospital level
• Facilitate the hospital Quality Assessment and Performance Improvement (QAPI) committee
• Prepare an annual evaluation of the hospital QAPI plan, including process and outcomes
• Oversee hospital-wide performance improvement (PI) projects identified through ongoing data-driven quality assessment
• Coordinate the hospital’s data collection procedures and provide ongoing support and education to staff regarding QAPI tools and reporting requirements; utilize data and collaborate with leadership to set priorities and provide guidance in their development of quality improvement work plans
• Serve as a resource to the medical staff, administrators, and other staff, including participation in root cause analyses, as indicated, to investigate potentially avoidable sentinel events
• Complete assignments accurately, in a timely manner, and within procedural guidelines
• Coordinate education for QAPI principles and regulatory standards as indicated
• Conduct training for staff
• Participate in the Joint Commission Accreditation process, including plan of action tracking and completion
• Perform other duties and projects as assigned by the facility administrator and corporate office

Requirements

• Associate degree or RN diploma required
• Healthcare experience related to clinical leadership and/or quality assessment and performance improvement
• Demonstrates proficient computer skills with MS Office products and electronic QAPI software solutions
• Ability to create and provide training programs on related quality performance topics
• Ability to work with minimal supervision and simultaneously manage multiple projects
• Knowledge of state and federal regulatory requirements, Joint Commission Accreditation
• Must successfully complete CPR certification and an Oceans approved behavioral health de-escalation program

Nice to have:

• Behavioral health experience
• CPHQ certification

Important Details

• Work Environment: Subject to many interruptions, occasional pressure due to multiple calls and inquiries; high-paced and stressful; must be able to cope mentally and physically to atmosphere; work requires spending approximately 90% or more of the time inside a building that offers protection from weather conditions but not necessarily from temperature changes