Job Description

Job Location Main Hospital Campus Headquarters - Madison, WV 25130 Position Type Full Time

The Director of Quality provides strategic leadership and oversight for all quality assurance initiatives, ensuring compliance with regulatory standards and fostering a culture of excellence in patient care. This role is accountable for the development, implementation, and evaluation of quality programs that align with organizational goals and regulatory requirements, including CMS, MBQIP, and Joint Commission reporting standards.

Boone Memorial Health has a culture that is dedicated to being patient-focused and performance-driven. The Director of Quality plays a pivotal role in upholding these values by ensuring the highest standards of care and creating a safe, compliant environment for patients and staff.

Essential Functions

Reasonable accommodations may be made to enable individuals with disabilities to perform these essential functions.

Clinical Quality & Performance Improvement

• Lead the planning, development, and execution of the organization’s quality assurance and performance improvement strategies in alignment with organizational goals.
• Establish measurable short-term and long-term objectives for quality improvement and performance monitoring.
• Foster a culture of quality and continuous improvement across all levels of the organization.
• Drive performance improvement initiatives to enhance operational efficiency, reduce costs, and improve patient outcomes.
• Facilitate cross-functional teams to implement process improvements and monitor progress.
• Provide training and guidance to staff on quality improvement tools and methodologies.

Data Management & Reporting

• Oversee data abstraction, collection, and analysis to monitor clinical performance and identify trends.
• Prepare and maintain accurate reports for internal stakeholders, committees, and regulatory agencies.
• Submit required data to external entities such as TJC, HQR, IQR, WVHA, and other applicable programs for Critical Access Hospitals.
• Utilize data analytics to forecast performance gaps and inform decision-making.

Regulatory Compliance & Policy Development

• Ensure compliance with all relevant healthcare regulations, accreditation standards, and industry best practices (e.g., CMS, Joint Commission, OHFLAC).
• Maintain and develop policies and procedures within areas of responsibility.
• Support survey readiness and accreditation activities to ensure ongoing compliance.

Collaboration & Patient Safety

• Partner with administrative and clinical leadership to improve efficiency, safety, and quality of care for all patients.
• Promote patient-centered care and organizational accountability for quality outcomes.

Competencies

• Excellent computer skills
• Ability to interpret and implement quality reporting programs/procedures
• Ability to analyze clinical data and identify trends
• Familiarity with CMS, Joint Commission, and MBQIP standards
• Experience with EHR systems
• Exceptional skill with data abstraction and analytics
• Competent with quality reporting platforms (HQR, IQR, NHSN, etc.)
• Experience in developing Quality Improvement Plans

Supervisory Responsibilities

• Supervises and actively participates in abstraction of quality indicators, data reporting, and performance improvement.
• Ability to lead organizational supervisors with performance improvement and be a resource when needed.
• Educate and train staff in quality and safety initiatives.

Physical demands

• Ability to perform various motor skills such as standing for long periods of time, walking, lifting (up to 50 pounds) using proper lifting techniques, stair climbing, reaching, bending, twisting, pushing, pulling, squatting, grasping and arm-hand coordination on a continuous basis.

Travel required

• Semi-annual MBQIP conference (in-state)

Education and experience

• Minimum 3–5 years in a leadership or management role within quality, performance improvement, or patient safety.
• Certified Professional in Healthcare Quality (CPHQ) preferred
• Must have a minimum of five years clinical experience in a hospital setting
• Skilled in facilitating quality committees, presenting data, and driving organizational engagement.
• Strong interpersonal skills for working with clinical teams, executives, and external agencies.

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Equal Employment Opportunity Policy Statement

Boone Memorial Hospital, Inc. provides equal employment opportunities to all personnel and applicants for employment and prohibits discrimination, harassment, prejudice, or behavior of any type based on race, color, religion, age, sex (including pregnancy), national origin, disability status, family medical history or genetic information, past or present military service, sexual orientation, gender identity or expression, family or parental status, political affiliation, or any other characteristic protected by federal, state or local laws.

Qualifications