Director of Quality and Risk Management

Job Summary

The Director of Quality Management is responsible for the strategic leadership, coordination, and oversight of quality-related functions that may include Accreditation, Infection Prevention, Employee Health, Service Quality, and Clinical Outcomes. This position works collaboratively with hospital leadership, physicians, staff, and external agencies to ensure high-quality, cost-effective, and safe healthcare delivery. The Director manages and interprets clinical data, supports compliance with regulatory standards, and drives continuous performance improvement throughout the facility.

• Leads development and implementation of departmental goals, plans, and standards in alignment with organizational strategy
• Directs departmental operations including staffing, budget, and performance improvement
• Oversees internal and external audits and regulatory readiness
• Coordinates complaint management and service recovery efforts
• Collaborates with executive leadership and medical staff on strategic quality initiatives
• Serves as subject matter expert to the Board of Trustees and other stakeholders
• Uses benchmarking and evidence-based practices to guide improvements in patient care
• Prepares professional reports and communicates findings to all levels of the organization
• Integrates data and analytics into clinical and administrative decision-making
• Leads committees and work groups focused on patient safety and quality

• Strong analytical, organizational, and leadership skills
• Advanced knowledge of accreditation standards and quality methodologies
• Effective interpersonal and communication skills
• Ability to manage multiple priorities and work independently
• Competence in statistical analysis, systems thinking, and change management
• Frequent sitting, keyboarding, and data analysis
• Occasional walking, standing, and lifting up to 25 lbs
• Manual dexterity required for operating office equipment
• Hospital environment with exposure to clinical areas
• May involve occasional exposure to infectious or hazardous materials with proper precautions
• Frequent interaction with internal staff and external agencies

• High school diploma or equivalent required
• Master’s degree in a health-related field preferred

• Current Registered Nurse license required
• Must meet licensure requirements within time frame required by facility policy
• Basic Life Support (BCLS) required
• Advanced Cardiac Life Support (ACLS) preferred
• Certified Professional in Healthcare Quality (CPHQ) preferred
• Certification in specialty area of practice highly recommended

• Minimum of five years of healthcare experience with at least three years in progressive management
• Experience in quality, case management, infection prevention, risk management, or accreditation required. Experience in leading hospital or system-level accreditation processes strongly preferred