Regional Director of Quality

Regional Director of Quality

Remote Position with 50% Travel Requirement
Registered Nurse (RN) License Required

Position Summary: 

This individual has oversight and responsibility over all quality, risk management and patient safety related activities within the multiple organizations for Quorum Health. Directs the efforts of all the performance improvement initiatives to ensure overall compliance with all regulatory standards including national, state, CMS, Joint Commission and other agencies. The director works with clinicians and administrators to improve overall patient safety and systems-level outcomes. Responsible for the facilities quality, patient safety and risk management programs with an emphasis on patient safety, and harm reduction. Supports, promotes and encourages a culture of safety throughout the organization.

Key Responsibilities:

• Facilitates alignment between improvement initiatives and the organizations strategic plan; directs the day to-day execution of the strategies and tactic necessary to successfully improve the outcomes and results of the organization.


• Responsible for maintaining the facilities system-wide Quality program; to include data collection, aggregating and analyzing data, maintaining policies and procedures and reporting to administrators, Medical Staff and the Board.


• Works closely with Clinical and Non-Clinical teams for improvement on key performance indicators, designs processes for new initiatives, services and other targets identified by Roosevelt General Hospital leadership.


• Serves as an internal consultant to administration, staff, and physicians in the areas of regulatory, process improvement, performance monitoring, and statistical analysis.


• Focuses on better healthcare value and quality, including the improvement of clinical outcomes, patient experience, patient safety, costs, revenue, productivity, efficiency, employee and physician satisfaction, and process reliability.


• Coordinate, manage and report Core Measures, ACO/MIPS/MACRA and meaningful use measures and other quality metrics as assigned. • Collects and reports HCAHPS data for the facility.


• Organize all Quality Management meetings, maintain minutes and makes recommendations to the committee based on best practice and current regulatory standards.


• Conduct internal audits and risk analysis as determined by the Quality Management Committee.


• Participate in nursing and physician peer review processes and chart reviews, as necessary.


• Mange and support physician peer review processes by ensuring the collection and analysis of data for provider FPPE/OPPE, scorecards, quality metrics, etc.


• Analyzes all assigned areas for opportunities of improvement and makes applicable recommendations for process, system, procedure, and operational changes to improve healthcare value and quality ie: Core Measures, Hospital Acquired Conditions, etc. 


• Assists in the establishment of operational performance measurements and the monitoring of trends in key performance indicators to evaluate effectiveness, reliability, efficiency, etc. using available information systems data. Where other data is necessary but not readily available, will design and implement appropriate data collection. Uses data from appropriate external sources, including comparative databases.


• Manages performance improvement projects, flow and alignment to assure milestones and key performance indicators are met within defined parameters. Documents the results of projects, and submits other documentation as requested.


• Participates in the Grievance Committee and works with department leaders to resolve investigations within the incident reporting system.


• Evaluate and document the effectiveness of the quality management system.


• Design, coordinate and maintain various aspects of the patient safety and risk management programs for all of the Hospital and its affiliated clinics.


• Review, investigate and analyze incidents for risk and adverse event identification, loss prevention and claims management purposes, including both potential and actual patient injury. Recommend interventions which will enhance the safety and well-being of patients, staff and organization at large.


• Mobilize departmental or administrative support to address unresolved high-risk practices. • Collaborate and coordinate with administrators and other departmental leaders on all patient safety/ risk management issues.

Knowledge, Skills & Abilities

• RN experience in a hospital setting


• Good communicator


• Strong accounting knowledge and experience 


• Excellent in Excel (pivot tables, V-lookup’s, etc)


• Critical thinking and problem-solving abilities.

Work Experience, Education & Certifications: 

• RN License to practice professional nursing is required 


• Registered Nurse with a strong analytical base, required


• A minimum of three (3) years’ experience in a hospital facility required, Quality/Risk leadership experience, preferred


• BSN required, Master’s degree in nursing, healthcare administration, or a similar field of study with a strong analytical base, preferred


• CPHQ (Certified Professional in Healthcare Quality), preferred