Quality Director

Riverside Health System•Smithfield, VA

1d•Onsite

About The Position

Opening in early 2026, Riverside Smithfield Hospital will bring high-quality healthcare closer to home for Isle of Wight County residents. Located on a beautifully landscaped 27-acre medical campus at 19339 Benn’s Grant Boulevard in Smithfield, the new hospital will provide modern facilities and comprehensive medical services to meet the growing needs of the community. The 200,000-square-foot, three-story facility will offer a range of essential healthcare services including an Emergency Department, Diagnostic Imaging Services, 38 Medical/Surgical beds, 12 Intensive Care Unit (ICU) beds and 4 Operating Rooms. Join our team and be a part of an exciting opportunity to shape the future of healthcare in Smithfield, delivering compassionate, patient-centered care in a state-of-the-art environment. We anticipate start dates to begin Fall, 2025. The Quality Director serves as a highly visible, energetic leader and champion for quality, safety, accreditation, infection prevention and care management throughout the organization, and is responsible for operational oversight and implementation of these programs. The Director promotes high reliability for recommended evidence based care for every patient, everywhere, every time assuring a focus on structure, people, process and technology to improve performance. Creates a continuous learning environment focused on patient and team member safety where just culture principles are applied and evident throughout the organization. Oversees the safety program that includes the safety culture survey and action planning and the safety event reporting system. The Director ensures compliance with accreditation and regulatory requirements at the national, state and local levels, and develops and maintains procedures necessary to meet regulatory requirements and achieve sustainable, organization-wide readiness. Provides oversight and coordinates care management functions hospital-wide including assessment, quality improvement activities related to care management, regulatory and accreditation requirements and compliance, appropriate admissions/status, observation stays, readmissions, and length of stay. Works closely and collaboratively with medical, nursing and clinical leadership to implement improvement strategies to continually improve quality and safety. Establishes an annual quality and safety plan and provides a year end summary report of progress toward goals and related achievements.

Requirements

Masters Degree, Healthcare, Behavioral Science, or related field (Required)
Experience in project development and project management
Requires strong analytical skills, including data management and data analysis, performance management models, methods and systems
Knowledge of clinical quality, patient safety and/or patient satisfaction performance measures and indicators, data definitions, and sources
Knowledge of relevant national databases and benchmarks
Knowledge of healthcare quality, safety, and satisfaction data design, collection, aggregation, and summarization
Knowledge of accreditation standards, CMS Conditions of Participation (COP), OSHA standards, ISO standards, NFPA, ANSI ST79 and VDEQ standards
Certified Professional in Healthcare Quality (CPHQ) - National Association of Healthcare Quality Healthcare Quality Certification Board within 120 Days (Required)

Nice To Haves

5-6 years relevant experience in hospital healthcare, with experience in quality, accreditation, safety and/or risk management (Preferred)
3-4 years supervisory or management experience (Preferred)
Certified Professional in Patient Safety (CPPS) - Institute for Healthcare Improvement (IHI) (Preferred)
Certified Professional in Health Care Risk Management (CPHRM) - American Hospital Association Certification Center (Preferred)
Healthcare Accreditation Certified Professionals (HACP) - Center for Improvement in Healthcare Quality (Preferred)
Six Sigma Green Belt - Riverside Health System (RHS) (Preferred)

Responsibilities

Serves as a highly visible, energetic leader and champion for quality, safety, accreditation, infection prevention and care management throughout the organization, and is responsible for operational oversight and implementation of these programs.
Promotes high reliability for recommended evidence based care for every patient, everywhere, every time assuring a focus on structure, people, process and technology to improve performance.
Creates a continuous learning environment focused on patient and team member safety where just culture principles are applied and evident throughout the organization.
Oversees the safety program that includes the safety culture survey and action planning and the safety event reporting system.
Ensures compliance with accreditation and regulatory requirements at the national, state and local levels, and develops and maintains procedures necessary to meet regulatory requirements and achieve sustainable, organization-wide readiness.
Provides oversight and coordinates care management functions hospital-wide including assessment, quality improvement activities related to care management, regulatory and accreditation requirements and compliance, appropriate admissions/status, observation stays, readmissions, and length of stay.
Works closely and collaboratively with medical, nursing and clinical leadership to implement improvement strategies to continually improve quality and safety.
Establishes an annual quality and safety plan and provides a year end summary report of progress toward goals and related achievements.
Designs, develops, and implements large scale clinical and operational improvement programs/activities for assigned areas.
Maintains current knowledge on regulatory requirements.
Provides research, evaluation, and recommendations for emerging quality and regulatory changes affecting assigned areas.
Serves in recruitment, orientation, training, mentoring and interim fulfillment of quality positions, as needed.
Performs complex, non-routine analysis of clinical reports and data from various information systems and provides interpretation and understanding of the analyses and studies in a narrative presentation with supporting graphs and charts.
Makes recommendations on methodology regarding data accuracy, availability, usefulness and other issues as necessary.
Assists in the development and implementation of process improvement projects requiring special data analysis.
Serves as a content expert on clinical guidelines, data, clinical initiatives and pay for performance strategies.
Provides strategic leadership toward completion of goals for the design, development, alignment, education, and implementation of quality and safety processes across assigned areas.
Acts as a key stakeholder in improving the patient experience with satisfaction data.
Assures accurate and timely submission of all required data and information for required and voluntary quality reporting programs.
Responsible for the overall participation and results of the patient safety culture survey, and utilizes the survey results in improvement efforts.
Serves as the Patient Safety Officer for the facility/entity.
Assures the hospital departments comply with established policies, procedures, quality assurance and quality control measures.
Provides oversight and direction for data management functions and processes for required quality reporting and performance measures ensuring data is accurate, obtained, submitted to external agencies as required, and internally reported timely and appropriate format.
Oversees measurement and analysis of quality, safety, infection prevention and control, and accreditation measures.
Provides leadership and direction to ensure compliance with accreditation regulatory requirements at the national, state, and local levels, and develops and maintains procedures necessary to meet regulatory requirements and achieve sustainable, organization-wide readiness.
Manages accreditation cycle process, CMS survey and certification process, and accreditation survey application management oversight.
Manages CMS complaint surveys and CMS validation surveys.
Manages DNV accreditation and ISO certification surveys.
In collaboration with Infection Prevention assures identification of infectious disease processes, surveillance, and epidemiological investigation.
Assures accurate and timely processes for preventing and controlling transmission of infectious agents.
Assures annual completion of the annual infection prevention and control program evaluation.
Assures communication and education related to infection prevention and control.