Director of Quality at St. James Hospital

Hornell, New York, United States -

Full Time

Start Date

Immediate

Expiry Date

16 Sep, 26

Salary

61.3

Posted On

18 Jun, 26

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Quality Assessment and Performance Improvement, Patient Safety, Regulatory Compliance, Infection Prevention and Control, Data Analytics, Root Cause Analysis, Lean Six Sigma, PDSA Cycles, Clinical Analytics, Strategic Thinking, Leadership, Collaboration, Healthcare Administration, Accreditation Readiness, Performance Metrics, Policy Development

Industry

Hospitals and Health Care

Description

Description Job Title: Quality Director Department: Quality Reports To: Chief Medical Officer / Chief Nursing Officer Job Type: Full-Time Job Summary The Director of Quality is responsible for the leadership, development, and oversight of hospital’s quality, patient safety, and regulatory compliance programs. This role ensures alignment with accreditation standards, including The Joint Commission, and drives performance improvement initiatives across the organization. The Director of Quality oversees the Infection Prevention program and works collaboratively with clinical and administrative leaders to promote a culture of safety, accountability, and continuous improvement. Key Responsibilities: Quality & Performance Improvement Lead the hospital-wide Quality Assessment and Performance Improvement (QAPI) program. 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. Oversee root cause analyses (RCAs), corrective action plans, and performance improvement activities. Report quality outcomes and trends to executive leadership and governing bodies. Chair and/or participate in key hospital committees related to quality, patient safety, and performance improvement. Infection Prevention & Control Oversight Provide oversight and leadership to the Infection Preventionist and infection control program. Ensure compliance with infection prevention standards and evidence-based practices. 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. Support education and initiatives to reduce infection risks across the organization. Regulatory Compliance & Accreditation Ensure hospital compliance with all applicable state, federal, and accreditation agencies, including CMS, The Joint Commission, and OSHA. Lead preparation for accreditation and regulatory surveys, audits, and inspections. Develop and maintain policies and procedures to align with evolving healthcare standards. Serve as the hospital’s primary resource for accreditation readiness and compliance. Leadership & Collaboration Partner with medical staff, nursing, and department leaders to advance quality and patient safety goals. Chair or participate in quality and patient safety committees. Provide guidance and education on quality improvement methodologies and best practices. Foster a culture of accountability, transparency, and high reliability. Requirements Education & Experience 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.

Responsibilities

Lead the hospital's quality, patient safety, and regulatory compliance programs, including the QAPI and Infection Prevention initiatives. Ensure alignment with accreditation standards such as The Joint Commission and CMS while driving continuous performance improvement.