Quality and Program Director

Description

Job Title: Hospital Quality and Program Director

Department: Quality

Reports To: Chief Medical Officer / Chief Nursing Officer

Job Type: Full-Time

Job Summary

The Hospital Quality and Program Director is responsible for the strategic leadership, development, and oversight of key operational areas, including Quality, Informatics, Case Management, Clinical Education, and Infection Prevention. This role ensures compliance with regulatory requirements, drives performance improvement initiatives, and fosters a culture of patient safety and excellence. The director collaborates with multidisciplinary teams to enhance clinical outcomes, optimize resource utilization, and implement evidence-based best practices across the organization.

Requirements

Key Responsibilities

Quality & Performance Improvement

• Develop and implement hospital-wide quality and patient safety programs aligned with regulatory and accreditation standards (e.g., The Joint Commission, CMS, OSHA).
• Utilize data analytics and performance metrics to drive continuous quality improvement (CQI) initiatives.
• Lead root cause analyses (RCAs), failure mode and effects analyses (FMEA), and action planning for quality events.
• Chair and/or participate in key hospital committees related to quality, patient safety, and performance improvement.

Clinical Informatics & Data Analytics

• Oversee the integration of healthcare technology and electronic health records (EHRs) to improve patient outcomes and operational efficiency.
• Collaborate with IT and clinical teams to optimize clinical decision support systems (CDSS), EHR workflows, and data reporting.
• Ensure compliance with health information regulations and promote data-driven decision-making.

Case Management & Utilization Review

• Provide leadership for case management, discharge planning, and utilization review to ensure appropriate resource utilization and patient flow.
• Work with medical staff and payers to minimize avoidable hospital stays and readmissions.
• Oversee denials management and ensure compliance with payer guidelines and reimbursement regulations.

Clinical Education & Staff Development

• Develop and oversee nursing and clinical education programs, ensuring staff competency and ongoing professional development.
• Implement training programs that align with evidence-based practices, regulatory changes, and organizational goals.
• Promote a culture of continuous learning and professional growth.

Infection Prevention & Control

• Lead the hospital's infection prevention and control (IPC) program, ensuring adherence to CDC, WHO, and regulatory guidelines.
• Monitor hospital-acquired infections (HAIs) and implement strategies to reduce infection risks.
• Provide education and training on infection control best practices.

Regulatory Compliance & Accreditation

• Ensure hospital compliance with state, federal, and accreditation agencies, including CMS, The Joint Commission, and OSHA.
• Prepare for and lead accreditation and regulatory surveys, audits, and inspections.
• Develop and maintain policies and procedures to align with evolving healthcare standards.

Leadership & Collaboration

• Serve as a key advisor to executive leadership on quality, safety, and program initiatives.
• Foster interdisciplinary collaboration among medical staff, nursing, administration, and ancillary departments.
• Mentor and develop department leaders to promote a culture of excellence, innovation, and accountability.

Qualifications

Education & ExperienceCopy Link

• Bachelor's Degree in Nursing (BSN), Healthcare Administration, or related field required; Master's Degree (MSN, MHA, MPH, or MBA) strongly preferred.
• Minimum of 5-7 years of progressive leadership experience in hospital quality, case management, infection prevention, or related areas.
• Extensive experience in regulatory compliance, accreditation processes, and performance improvement methodologies (e.g., Lean, Six Sigma, PDSA cycles).
• Experience working with EHR systems, clinical analytics, and data-driven decision-making.

Certifications (Preferred/Required)

• Certified Professional in Healthcare Quality (CPHQ)
• Certified Case Manager (CCM) or Accredited Case Manager (ACM)
• Certified in Infection Control (CIC)
• Lean Six Sigma Green/Black Belt (preferred)

Skills & Competencies

• Strong leadership, communication, and collaboration skills.
• Expertise in data analysis, reporting, and quality improvement methodologies.
• Deep understanding of regulatory and compliance standards in healthcare.
• Ability to lead multidisciplinary teams and drive culture change.
• Strategic thinking with the ability to execute hospital-wide initiatives effectively.

Salary : $47 - $57