What are the responsibilities and job description for the Director of Quality position at Livingston HealthCare?
JOB SUMMARY:
The Director of Quality is responsible for developing, implementing, and maintaining a comprehensive quality management and performance improvement program. This includes oversight of patient safety, risk management, infection prevention, and continuous improvement initiatives. The Director ensures that the hospital meets or exceeds standards established by CMS, and state and federal regulatory agencies, while supporting the hospital’s mission to deliver safe, high-quality, patient-centered care.
ESSENTIAL FUNCTIONS, DUTIES AND RESPONSIBILITIES:
- Develop, coordinate, and oversee the hospital’s Quality, Patient Safety, Infection Prevention, and Performance Improvement programs.
- Monitor key performance indicators, clinical outcomes, and patient satisfaction metrics to identify opportunities for improvement.
- Ensure compliance with Critical Access Hospital Conditions of Participation (CoPs) and other applicable regulatory requirements.
- Manage and oversee hospital-wide quality committees, including Quality Improvement, Patient Safety Committee, and Infection Prevention Committee.
- Focuses on the facilitation of clinical and system problem identification, data collection, analysis, reporting, and direction of improvements.
- Lead root cause analyses (RCA), failure mode and effects analyses (FMEA), and other quality review processes following adverse events or near misses.
- Oversight and coordination of medical peer review process as directed by Chief of Staff and Medical Executive Committee.
- Coordinate survey readiness activities, including preparation for licensure surveys.
- Partner with Risk Management and Infection Prevention to ensure alignment between quality and safety initiatives.
- Oversee the collection, analysis, and reporting of clinical quality data to CMS (e.g., Hospital Compare, HCAHPS, MBQIP measures).
- Provide education and training to staff and medical staff on quality improvement principles, patient safety, and regulatory updates.
- Prepare and present regular quality reports to the Board of Quality Directors and executive leadership.
- Maintain several committee memberships
- Participate in the development of a wide variety of policies and procedures as needed or requested.
- Serve as a hospital resource and advocate for a culture of safety, accountability, and continuous improvement.
- Aligns the organization with national quality and patient safety initiatives such as Institute for Healthcare Improvement (IHI), CMS Core Measures, PIN, and others as identified.
- Provide quality improvement and patient safety resources and coaching to leadership and staff as needed.
- Development and maintenance of assigned operating budgets within allocated resources.
- Maintains current understanding of and knowledge of management and leadership techniques and skills.
- Stay current in in literature and regulatory agency requirements related to quality and patient safety.
- Provides oversight for programs and staff reporting to the Quality Department.
- Provides leadership and oversight of the hospital’s education program to ensure compliance with CMS Conditions of Participation and other regulatory standards across all departments and disciplines.
- Assists and participates in orientation and quality education for new employees and clinical departments.
- Performs other duties as required.
OTHER FUNCTIONS, DUTIES AND RESPONSIBILITIES OF ALL EMPLOYEES:
- Supports and models individual behavior consistent with the Standards of Excellence and the mission, vision and values of Livingston Healthcare.
- Demonstrates commitment to customer service by:
- Building effective working relationships and treating others with respect.
- Interacting with customers (patients, co-workers and visitors) in a warm and friendly way.
- Taking immediate action to meet customers’ needs or request.
- Attentive to each customer concern.
- Demonstrates and encourages an ethic of open and effective communication and teamwork throughout the organization.
- Adheres to Livingston HealthCare’s Code of Conduct and Livingston HealthCare and departmental compliance policies.
The above statements reflect the general duties considered necessary to describe the principal functions of the job as identified and shall not be considered as a detailed description of all the work requirements which may be inherent in the position.
QUALIFICATIONS (Required):
- Education:
- Bachelor's Degree in Nursing.
- Master's Degree in Nursing preferred.
- Experience:
- Minimum of 5 years of experience in nursing, experience in healthcare quality preferred.
- Experience in a Critical Access Hospital or rural healthcare environment strongly preferred.
- Prior leadership or management experience required.
- Licensure/Certification:
- Current Montana RN License.
- Certified Professional in Healthcare Quality (CPHQ) or equivalent certification (or obtained within 1 year of hire).
- Skills and Competencies:
- Strong knowledge of CMS CAH Conditions of Participation, and other regulatory requirements.
- Proven ability to lead multidisciplinary teams and drive organizational change.
- Excellent analytical, organizational, and communication skills.
- Proficient in data analysis, report writing, and use of performance improvement tools (e.g., PDSA, Lean, Six Sigma).
- Ability to manage multiple priorities in a fast-paced, rural healthcare environment.
- Demonstrates integrity, professionalism, and commitment to patient-centered care.