Director of Quality Management (RN)

About the role

The RN Director of Quality Management leads the hospital’s quality improvement and patient safety initiatives, ensuring compliance with regulatory standards and driving continuous performance improvement across the organization.

Key responsibilities

• Develop, implement, monitor, and assure an integrated Quality Program aligned with the hospital’s Quality Improvement/Patient Safety Plan.
• Coordinate activities of the Continuous Quality Improvement Committee and related initiatives.
• Supervise the Medical Staff and Quality Team, providing leadership on quality indicators and performance measures.
• Conduct monitoring, auditing, data aggregation, analysis, and reporting of quality findings.
• Oversee the Peer Review process (OPPE/FPPE) for medical staff credentialing and workflow.
• Provide data and reports to support physician/LIP credentialing and peer review processes.
• Review medical records according to screening criteria and prepare excerpts for quality committee review.
• Direct the Performance Improvement program and integrate it with patient safety functions.
• Ensure appropriate reporting of adverse events to external agencies.
• Participate in safety rounds, accreditation survey readiness, and implement corrective action plans.
• Lead all activities related to accreditation and hospital licensure.
• Develop and maintain professional, organizational, and community relationships.

Required profile

• Bachelor’s degree in health/public health administration, business administration, nursing or a closely related field; Master’s degree preferred.
• At least three years of progressively responsible experience in quality improvement or nursing quality management.
• CPHQ or equivalent certification preferred.
• Working knowledge of health‑care delivery principles, Joint Commission, CMS, and other regulatory standards.
• Understanding of organizational theories, management techniques, and professional communication.
• Thorough knowledge of OPPE/FPPE processes.

Required skills

• Proficiency with Epic electronic health record system.
• Strong command of Microsoft Office applications (Word, Excel, Outlook, PowerPoint).