Senior Director of Quality

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Current Bay Area Hospital Employee: If you are a current Bay Area Hospital employee, please apply through the Workday internal career site.

The future looks bright at Bay Area Hospital, and we are always searching for quality people to join our team. We offer a great atmosphere, competitive pay, a wide array of benefits, and many growth opportunities for our employees.

Job Description:

EXPECTATION FOR ALL EMPLOYEES

Support the organization’s mission, vision and values by adhering to the behavioral standards of Bay Area Hospital.  Comply with all laws and regulations affecting Bay Area Hospital.  Be familiar with and adhere to the Bay Area Hospital Code of Conduct and Compliance Program.  Effective communication skills and the ability to work effectively with people from various backgrounds are critical.

POSITION SUMMARY

The Senior Director of Quality provides strategic and operational leadership for Bay Area Hospital’s quality management, patient safety, performance improvement, infection prevention, accreditation, and regulatory readiness programs. The Senior Director partners with executive leadership, medical staff, nursing leadership, and operational leaders to advance a culture of safety, continuous improvement, accountability, and high reliability.

This position is responsible for developing, implementing, and evaluating organizational quality strategies; monitoring clinical and operational outcomes; ensuring ongoing accreditation and regulatory compliance; and leading improvement initiatives designed to enhance patient safety, clinical quality, patient experience, and organizational performance.

PRINCIPLE DUTIES AND RESPONSIBILITIES

• Provides leadership and administrative oversight for the Quality Division, including quality improvement, patient safety, infection prevention, accreditation and regulatory readiness, and other assigned quality functions.
• Develops and implements the organization’s quality and patient safety strategy in alignment with Bay Area Hospital’s strategic priorities, regulatory requirements, and evidence-based practices.
• Leads organizational readiness for The Joint Commission surveys and other accreditation and regulatory reviews, including ongoing compliance monitoring, survey preparation, corrective action planning, and sustained improvement.
• Provides oversight of organizational performance improvement activities, including identification of improvement opportunities, development of measurable goals, implementation of improvement plans, and evaluation of outcomes.
• Partners with clinical, medical staff, and operational leaders to improve patient outcomes and advance a culture of safety, reliability, accountability, and continuous improvement.
• Provides leadership for monitoring, analysis, and improvement of organizational quality measures, including CMS quality programs, readmissions, patient safety indicators, hospital-acquired conditions, infection prevention measures, and other applicable quality metrics.
• Ensures quality initiatives and reporting requirements are effectively managed to support regulatory, contractual, payer, and organizational requirements.
• Provides leadership and oversight for patient safety programs, including event review, root cause analysis, corrective action planning, and identification of system-level opportunities for improvement.
• Promotes the use of data, evidence-based practices, benchmarking, and performance improvement methodologies to identify trends, evaluate outcomes, and drive organizational improvement.
• Collaborates with Patient Experience and operational leadership to identify opportunities to improve patient experience outcomes, including HCAHPS and other patient feedback measures.
• Serves as a subject matter expert and organizational resource regarding quality, patient safety, accreditation, regulatory requirements, and performance improvement.
• Provides leadership, coaching, development, and accountability for leaders and team members within assigned areas of responsibility.
• Builds and maintains a collaborative, engaged, and high-performing Quality team.
• Provides regular quality and patient safety reporting to executive leadership, medical staff leadership, hospital committees, and the Board of Directors or Board committees, as assigned.
• Partners with senior leadership in the development and execution of organizational strategic priorities related to quality, safety, regulatory compliance, and clinical performance.
• Leads and/or participates in organizational committees, councils, and workgroups related to quality, patient safety, accreditation, infection prevention, and performance improvement.
• Assists assigned leaders in establishing departmental goals, performance expectations, and professional development objectives and monitors progress toward established goals.
• Participates in the development and management of departmental operating, personnel, and capital budgets.
• Maintains awareness of changes in federal and state regulations, accreditation standards, industry trends, and evidence-based practices affecting hospital quality and patient safety.
• Performs other duties and responsibilities as assigned.

SKILLS AND ABILITIES

• Comprehensive knowledge of healthcare quality management, patient safety, performance improvement, accreditation, and regulatory compliance in an acute care hospital environment.
• Demonstrated knowledge of The Joint Commission, CMS Conditions of Participation, and other applicable healthcare regulatory and accreditation requirements.
• Demonstrated ability to develop and execute organizational quality and patient safety strategies.
• Strong knowledge of continuous improvement methodologies, root cause analysis, corrective action planning, and quality management tools.
• Demonstrated ability to analyze complex quality and clinical performance data, identify trends and risks, and translate findings into actionable improvement strategies.
• Demonstrated ability to communicate effectively with executive leaders, physicians, clinical leaders, employees, regulatory agencies, and other stakeholders.
• Strong leadership, collaboration, negotiation, facilitation, and conflict-resolution skills.
• Proven ability to lead people, projects, and organizational change across multidisciplinary teams.
• Demonstrated ability to coach, mentor, develop, and inspire leaders and team members.
• Excellent written and verbal communication skills, including the ability to prepare executive-level reports, presentations, policies, procedures, and regulatory responses.
• Strong analytical, critical-thinking, problem-solving, and root-cause analysis skills.
• Ability to lead through influence and establish credibility across clinical and non-clinical areas of the organization.
• Ability to prioritize and manage multiple complex initiatives and competing organizational priorities.
• Demonstrated sound judgment and ability to make timely decisions based on available information, regulatory requirements, organizational risk, and patient safety considerations.
• Demonstrates integrity, accountability, professionalism, discretion, and a commitment to ethical decision-making.
• Demonstrates the ability to translate organizational strategy into measurable goals, actions, and accountability.
• Maintains regular, consistent, and punctual attendance at the assigned job location.

EXPECTATION FOR ALL EMPLOYEES

Support the organization’s mission, vision and values by adhering to the behavioral standards of Bay Area Hospital.  Comply with all laws and regulations affecting Bay Area Hospital.  Be familiar with and adhere to the Bay Area Hospital Code of Conduct and Compliance Program.  Effective communication skills and the ability to work effectively with people from various backgrounds are critical.

POSITION SUMMARY

The Senior Director of Quality provides strategic and operational leadership for Bay Area Hospital’s quality management, patient safety, performance improvement, infection prevention, accreditation, and regulatory readiness programs. The Senior Director partners with executive leadership, medical staff, nursing leadership, and operational leaders to advance a culture of safety, continuous improvement, accountability, and high reliability.

This position is responsible for developing, implementing, and evaluating organizational quality strategies; monitoring clinical and operational outcomes; ensuring ongoing accreditation and regulatory compliance; and leading improvement initiatives designed to enhance patient safety, clinical quality, patient experience, and organizational performance.

PRINCIPLE DUTIES AND RESPONSIBILITIES

• Provides leadership and administrative oversight for the Quality Division, including quality improvement, patient safety, infection prevention, accreditation and regulatory readiness, and other assigned quality functions.
• Develops and implements the organization’s quality and patient safety strategy in alignment with Bay Area Hospital’s strategic priorities, regulatory requirements, and evidence-based practices.
• Leads organizational readiness for The Joint Commission surveys and other accreditation and regulatory reviews, including ongoing compliance monitoring, survey preparation, corrective action planning, and sustained improvement.
• Provides oversight of organizational performance improvement activities, including identification of improvement opportunities, development of measurable goals, implementation of improvement plans, and evaluation of outcomes.
• Partners with clinical, medical staff, and operational leaders to improve patient outcomes and advance a culture of safety, reliability, accountability, and continuous improvement.
• Provides leadership for monitoring, analysis, and improvement of organizational quality measures, including CMS quality programs, readmissions, patient safety indicators, hospital-acquired conditions, infection prevention measures, and other applicable quality metrics.
• Ensures quality initiatives and reporting requirements are effectively managed to support regulatory, contractual, payer, and organizational requirements.
• Provides leadership and oversight for patient safety programs, including event review, root cause analysis, corrective action planning, and identification of system-level opportunities for improvement.
• Promotes the use of data, evidence-based practices, benchmarking, and performance improvement methodologies to identify trends, evaluate outcomes, and drive organizational improvement.
• Collaborates with Patient Experience and operational leadership to identify opportunities to improve patient experience outcomes, including HCAHPS and other patient feedback measures.
• Serves as a subject matter expert and organizational resource regarding quality, patient safety, accreditation, regulatory requirements, and performance improvement.
• Provides leadership, coaching, development, and accountability for leaders and team members within assigned areas of responsibility.
• Builds and maintains a collaborative, engaged, and high-performing Quality team.
• Provides regular quality and patient safety reporting to executive leadership, medical staff leadership, hospital committees, and the Board of Directors or Board committees, as assigned.
• Partners with senior leadership in the development and execution of organizational strategic priorities related to quality, safety, regulatory compliance, and clinical performance.
• Leads and/or participates in organizational committees, councils, and workgroups related to quality, patient safety, accreditation, infection prevention, and performance improvement.
• Assists assigned leaders in establishing departmental goals, performance expectations, and professional development objectives and monitors progress toward established goals.
• Participates in the development and management of departmental operating, personnel, and capital budgets.
• Maintains awareness of changes in federal and state regulations, accreditation standards, industry trends, and evidence-based practices affecting hospital quality and patient safety.
• Performs other duties and responsibilities as assigned.

SKILLS AND ABILITIES

• Comprehensive knowledge of healthcare quality management, patient safety, performance improvement, accreditation, and regulatory compliance in an acute care hospital environment.
• Demonstrated knowledge of The Joint Commission, CMS Conditions of Participation, and other applicable healthcare regulatory and accreditation requirements.
• Demonstrated ability to develop and execute organizational quality and patient safety strategies.
• Strong knowledge of continuous improvement methodologies, root cause analysis, corrective action planning, and quality management tools.
• Demonstrated ability to analyze complex quality and clinical performance data, identify trends and risks, and translate findings into actionable improvement strategies.
• Demonstrated ability to communicate effectively with executive leaders, physicians, clinical leaders, employees, regulatory agencies, and other stakeholders.
• Strong leadership, collaboration, negotiation, facilitation, and conflict-resolution skills.
• Proven ability to lead people, projects, and organizational change across multidisciplinary teams.
• Demonstrated ability to coach, mentor, develop, and inspire leaders and team members.
• Excellent written and verbal communication skills, including the ability to prepare executive-level reports, presentations, policies, procedures, and regulatory responses.
• Strong analytical, critical-thinking, problem-solving, and root-cause analysis skills.
• Ability to lead through influence and establish credibility across clinical and non-clinical areas of the organization.
• Ability to prioritize and manage multiple complex initiatives and competing organizational priorities.
• Demonstrated sound judgment and ability to make timely decisions based on available information, regulatory requirements, organizational risk, and patient safety considerations.
• Demonstrates integrity, accountability, professionalism, discretion, and a commitment to ethical decision-making.
• Demonstrates the ability to translate organizational strategy into measurable goals, actions, and accountability.
• Maintains regular, consistent, and punctual attendance at the assigned job location.

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Bay Area Hospital is an Equal Opportunity Employer.

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