POSITION SUMMARY
The Director of Quality and Risk Management is responsible for leading, developing, implementing, and evaluating the organization’s quality improvement, patient safety, regulatory compliance, accreditation, and risk management programs. This position provides strategic oversight of performance improvement initiatives, regulatory readiness, patient safety activities, and risk mitigation efforts to ensure high-quality patient care and organizational compliance.
The Director serves as a resource and advisor to leadership, medical staff, department directors, and governing bodies regarding quality, safety, accreditation, and compliance matters
CORE FUNCTIONS
- Lead and oversee the hospital-wide Quality Assessment and Performance Improvement (QAPI) program.
- Develop, implement, and monitor quality improvement initiatives to enhance patient outcomes and organizational performance.
- Coordinate and facilitate Continuous Quality Improvement (CQI) activities across all departments.
- Direct the organization’s risk management program, including identification, investigation, evaluation, and mitigation of clinical and operational risks.
- Analyze quality, patient safety, and risk management data to identify trends and opportunities for improvement.
- Lead investigations of adverse events, near misses, grievances, and potentially compensable events, ensuring appropriate follow-up and corrective actions.
- Maintain ongoing compliance with federal, state, CMS, and accreditation standards and requirements.
- Coordinate organizational readiness and serve as lead facilitator for regulatory and accreditation surveys.
- Provide education, training, and consultation to leadership, medical staff, and employees regarding quality improvement, patient safety, risk management, and regulatory compliance.
- Prepare and present quality, patient safety, risk, and compliance reports to executive leadership, medical staff committees, and the governing board.
- Support medical staff committees and performance improvement teams through data analysis, reporting, and strategic guidance.
- Collaborate with department leaders to develop, implement, and monitor corrective action plans and performance improvement initiatives.
- Oversee quality reporting systems, occurrence reporting processes, and performance measurement activities.
- Promote a culture of patient safety, regulatory compliance, accountability, and continuous improvement throughout the organization.
- Serve as a key resource and advisor to senior leadership on quality, risk, patient safety, and accreditation matters.
- Ensure confidentiality and integrity of patient, organizational, and quality-related information.
- Lead special projects and strategic initiatives related to quality, safety, compliance, and organizational excellence.
MINIMUM QUALIFICATIONS
Bachelor’s degree in Nursing, Healthcare Administration, Public Health, or a related healthcare field.
Minimum three (3) years of experience in healthcare quality, risk management, regulatory compliance, accreditation, patient safety, or hospital leadership.
Experience with quality improvement methodologies, performance improvement programs, and regulatory survey readiness.
Demonstrated ability to analyze data, identify trends, and implement performance improvement initiatives.
Strong leadership, organizational, project management, and decision-making skills. Excellent written, verbal, and presentation communication skills.
Proficiency in Microsoft Office applications and healthcare quality/risk management databases. Ability to work collaboratively with physicians, senior leadership, department directors, and staff to achieve organizational goals.
PREFERRED QUALIFICATIONS
Knowledge of Critical Access Hospital (CAH) Conditions of Participation, CMS requirements, and accreditation standards preferred.
Additional related education and/or experience preferred.