The Director of Quality Management is responsible for overseeing the operational, financial, and personnel resources related to quality performance, accreditation/licensing, patient relations, infection prevention, policy and procedure process management, and patient safety within the healthcare enterprise. Utilizing a systems-based approach, the Director ensures compliance with regulatory and accreditation requirements, fosters a culture of continuous quality improvement, and supports hospital-wide risk management activities.
Key Responsibilities:
- Direct and oversee hospital-wide quality management programs to ensure compliance with Joint Commission and other regulatory requirements.
- Facilitate compliance with core measures and patient safety initiatives.
- Lead Hospital Patient Safety/Quality Council meetings and disseminate relevant quality and performance information enterprise-wide.
- Prepare and present quality reports to the Medical Executive Committee and Hospital Governing Board.
- Oversee hospital risk management activities, including root cause analysis and the implementation of lessons learned from defects.
- Coordinate the Medical Staff Peer Review process to support continuous performance improvement.
- Manage various certification, patient safety, and regulatory programs through delegation and oversight.
- Ensure adherence to policy and procedure process management, ensuring all documents align with regulatory and best practice standards.
- Collaborate with hospital leadership, medical staff, and frontline employees to drive a culture of quality and patient-centered care.
- Serve as a liaison between the hospital and external regulatory agencies regarding quality, accreditation, and patient safety initiatives.
Reporting Structure:
- Reports directly to the Chief Executive Officer (CEO) and the Board of Directors.
Qualifications:
- Bachelor's degree in healthcare administration, nursing, public health, or a related field (Masters degree preferred).
- Minimum of 5-7 years of experience in healthcare quality management, accreditation, or patient safety.
- Strong knowledge of regulatory and accreditation standards (e.g., Joint Commission, CMS, state licensing bodies).
- Experience in risk management, peer review processes, and root cause analysis.
- Demonstrated leadership skills with the ability to influence and drive quality initiatives at an enterprise level.
- Excellent communication, analytical, and problem-solving skills.
- Certification in healthcare quality (e.g., CPHQ) or patient safety (e.g., CPPS) preferred.
This is a key leadership role within the organization, offering an opportunity to shape and drive quality, safety, and regulatory excellence across the hospital enterprise.