Job Description

Reporting to the Vice President of Quality and the Regional President, the Regional Director of Quality Services oversees efforts to ensure high-quality clinical care, service excellence, and operational efficiency across the Region. This role ensures compliance with all regulatory and accreditation standards, leads the Quality Assessment/Performance Improvement plan, and aligns regional initiatives with System goals. The Director manages a department covering quality reporting, patient experience, safety, infection prevention, and regulatory compliance, while collaborating closely with System-level quality leaders including the System Quality Director, System Infection Control Officer, System Patient Experience Officer, and System Regulatory and Accreditations Officer.

'PRINCIPAL ACCOUNTABILITIES/RESPONSIBILITIES:

• Oversees each facility’s Quality Assessment/Performance Improvement activities including departmental plans, reporting, action and/or recommendations and follow up with hospital departments/Medical Staff and hospital board as necessary
• Ensures Patient safety assessment, monitoring, reporting, and action plan implementation throughout Hospital departments and across the care continuum. Ensures alignment with System Patient Safety Officer
• Thorough understanding of all regulatory requirements and guidelines from agencies including CMS, State Department of Health, accreditation agencies, OSHA, and other such agencies and leading efforts to ensure compliance including facilitating survey preparation and activities to ensure continual readiness and assure timely submission of Plans of Corrections
• Mandatory reporting requirements for hospitals and healthcare organizations and ensuring timely and accurate compliance and appropriate follow up as needed
• Aligns organizational initiatives with System goals and strategies to provide the highest quality care, patient experience, and cost-effective care
• Assist in the development and management of the budgets of the Quality Services for assigned regional facilities and provide leadership to Quality Managers at each facility
• Oversee all areas of the Quality Services functions and align with system functions, including infection prevention, patient safety, patient experience, quality reporting, regulatory compliance and accreditation.
• Supervisory Responsibilities - Day to day supervision of direct reports; including responsibility for hiring, dismissal, disciplinary and performance reviews.