Director Quality/Risk Management & Regulatory Compliance

1. POSITION PURPOSE (Summary)

The Director of Quality, Risk Management, and Regulatory Compliance provides strategic leadership and operational oversight for the hospital’s quality improvement, patient safety, risk mitigation, and regulatory readiness programs. This role ensures the organization meets or exceeds all federal, state, and accreditation requirements while fostering a culture of safety, high reliability, and continuous improvement across all clinical and operational departments, as well as clinical excellence, workforce competency. This position is also responsible for oversight of the Education Department and Medical Staff Credentialing. This position reports to the CNO/CCO and may be required to participate in a Nursing Leadership On-Call rotation providing guidance and back up to nursing staff.

2. POSITION QUALIFICATIONS

Education: Associate's degree in nursing at minimum, Bachelor's degree preferred.
Experience: Minimum of three years in an acute care facility and demonstrates a clear working knowledge of general hospital operations, TJC, OSHA, Medicare CoP, and state requirements.

Other Qualifications/Certificates:

1. Current license as Registered Professional Nurse 2. Advance certificate and training preferred

American Disabilities
1. Essential Duties: The Director of Quality Management and Regulatory Compliance is responsible for the oversight of all quality, The Joint Commission and regulatory requirements. Great communication, management and supervisory skills are inherent in the position. The ability to retrieve, communicate or otherwise express information in a written, auditory and visual fashion is essential. Written, telephone, and manual dexterity skills are required as well as good presentation skills.
2. Physical Requirements:
The position requires a considerable amount of physical work not to exceed the lifting of 50 pounds. Any workload exceeding 50 pounds will require human or mechanical assistance. The individual must be able to lift supplies. The individual must also be able to quickly maneuver throughout halls, stairways, and patients’ rooms in response to hospital emergencies. Interpretation of environmental input requires visual and auditory skills. In the event there is a need to evacuate the building, heavy lifting will be required to carry patients to safety.
3. Working Conditions:
The Quality Manager spends approximately 100% of their time in an air-conditioned or heated environment with varying exposures to excessive humidity or noise.
4. Personal Protective Equipment:
As appropriate to the conditions/surroundings.

3. KEY RESPONSIBILITIES

The key responsibilities are summarized here. The employee with responsibilities in this position will be expected to:
Quality & Performance Improvement

• Lead the development, implementation, and evaluation of the hospital-wide Quality and Performance Improvement Plan.
• Oversee data collection, analysis, and reporting for quality metrics, including CMS, Leapfrog, NHSN, and internal KPIs.
• Facilitate multidisciplinary performance improvement initiatives using the IDEA cycle, PDSA, or other evidence-based methodologies.
• Support clinical leaders in reducing variation, improving outcomes, and enhancing patient experience.
• Present quality dashboards and performance trends to executive leadership, and medical staff committees.

Risk Management

• Direct the hospital’s risk management program, including event reporting, investigation, root cause analysis (RCA), and proactive risk assessments.
• Manage claims, litigation coordination, and communication with insurers.
• Identify systemic risks and collaborate with leaders to implement corrective actions and preventive strategies.
• Serve as a resource for staff regarding risk mitigation, disclosure processes, and patient safety best practices.

Regulatory & Accreditation Compliance

• Ensure continuous readiness for regulatory surveys (CMS, Joint Commission, state health department).
• Lead mock surveys, tracer activities, and compliance audits.
• Interpret regulatory standards and communicate requirements to leadership and frontline teams.
• Oversee policy and procedure development to ensure alignment with current regulations and evidence-based practice.
• Coordinate survey responses, corrective action plans, and ongoing monitoring.

Leadership & Collaboration

• Provide leadership, coaching, and development for hospital leaders.
• Partner with medical staff, nursing, and operational leaders to drive a culture of safety and accountability.
• Serve as a key advisor to the Chief Nursing Officer, Officer, and executive team on quality and regulatory matters.
• Facilitate committees such as Quality Council, Patient Safety Committee, and Environment of Care.

Education & Staff Development

• Oversee the hospital’s education department, including orientation, annual competencies, and ongoing staff development.
• Ensure compliance with mandatory education requirements (e.g., CMS, OSHA, Joint Commission).
• Develop and implement training programs that support clinical excellence, patient safety, and regulatory compliance.
• Collaborate with department leaders to identify educational needs and create targeted learning plans.
• Support leadership development and succession planning initiatives.

Medical Staff Services & Credentialing

• Direct the medical staff credentialing, privileging, and reappointment processes in accordance with regulatory and accreditation standards.
• Ensure timely and accurate verification of credentials, licensure, certifications, and background checks.
• Oversee the Medical Staff Office and support the Medical Executive Committee, Credentials Committee, and other medical staff leadership bodies.
• Maintain the accuracy and integrity of provider files and credentialing databases.
• Ensure compliance with bylaws, rules and regulations, and privileging criteria.
• Partner with medical staff leaders to support peer review, OPPE/FPPE, and provider performance improvement.

Key Competencies

• Strong analytical and data interpretation skills
• Excellent communication and presentation abilities
• Ability to lead through influence and collaboration
• High reliability and systems-thinking mindset
• Strong organizational and project management skills
• Ability to manage sensitive information with discretion