Director, Quality Improvement and Compliance

Trinity Health

About The Position

The Quality Director provides strategic leadership and operational oversight for the Performance Improvement (PI), Quality, and Compliance programs within Trinity Health PACE. This role ensures organizational adherence to CMS, state, and Trinity Health regulatory standards while driving a culture of safety, continuous improvement, accountability, and exceptional participant outcomes. The Quality Director collaborates closely with the Executive Director, Medical Director, Interdisciplinary Team (IDT), and corporate partners to design, implement, and monitor systems that support high-quality, person-centered care for all PACE participants. Our Commitment Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law. Trinity Health is one of the largest not-for-profit, faith-based health care systems in the nation. Together, we’re 121,000 colleagues and nearly 36,500 physicians and clinicians caring for diverse communities across 27 states. Nationally recognized for care and experience, our system includes 101 hospitals, 126 continuing care locations, the second largest PACE program in the country, 136 urgent care locations, and many other health and well-being services. Based in Livonia, Michigan, in fiscal year 2023, we invested $1.5 billion in our communities through charity care and other community benefit programs. For more information, visit http://www.trinity-health.org. You can also follow Trinity Health on LinkedIn.

Responsibilities

Lead the PACE Alexandria QAPI program, ensuring alignment with CMS standards and Trinity Health system expectations.
Analyze data trends specific to our region (rural access barriers, caregiver strain, behavioral health needs, transportation delays, coordination challenges) and translate them into meaningful improvement initiatives.
Facilitate monthly QI meetings with discipline leaders; prepare quality dashboards and reports for Trinity Health PACE leadership and governance committees.
Lead RCA and FMEA processes related to participant safety events, transportation incidents, and care coordination gaps.
Ensure QAPI documentation meets regulatory standards and reflects Alexandria‑specific improvement work.
Maintain full readiness for CMS and state surveys, including unannounced visits.
Conduct mock surveys with focus on interdisciplinary coordination, care planning, medication management, and home care documentation quality.
Monitor changes in Louisiana regulations impacting PACE operations and ensure timely implementation.
Oversee incident reporting and investigation processes, including participant falls, pressure injuries, behavioral events, transportation concerns, and community setting risks.
Lead safety huddles and quality rounds in the center and collaborate with the Home Care Coordinator on trends in participants’ homes.
Ensure timely and accurate reporting of mandatory events to the Louisiana Department of Health and CMS.
Manage data integrity for quality indicators, participant experience surveys, utilization patterns, and IDT performance metrics.
Produce reports that support strategic decision-making related to nursing home utilization, hospital readmissions, caregiver support, transportation reliability, and contracted provider performance.
Partner with Trinity Health Corporate Quality and IT to optimize EMR reports and dashboards.
Serve as a trusted partner to the Executive Director and leadership team in driving organizational priorities.
Provide quality-related coaching and education across all disciplines, with special attention to clinical documentation, assessment timeliness, and coordination of care.
Collaborate with partners such as SNFs, home care agencies, behavioral health providers, and acute care systems to improve transitions and service quality.
Support development of a mission-driven culture of safety, respect, and continuous learning.