Director of Quality - Healthcare
Community Health Systems, La Follette, Tennessee, United States, 37766
Job Summary
The Director of Quality is responsible for leading the organization's quality improvement, patient safety, and regulatory compliance programs. This role partners closely with executive leadership, medical staff, and department leaders to drive a culture of continuous improvement, ensure regulatory readiness, and improve clinical and operational outcomes. The Director of Quality oversees performance improvement initiatives, monitors quality metrics, and ensures delivery of safe, high-quality, patient-centered care across the organization.
Essential Responsibilities
Quality & Performance Improvement
Develop, implement, and oversee quality improvement and patient safety programs aligned with organizational goals and regulatory requirements.
Monitor, analyze, and trend quality, safety, and performance metrics to identify risks, gaps, and opportunities for improvement.
Lead and support Root Cause Analyses (RCA), Failure Modes and Effects Analysis (FMEA), and other performance improvement methodologies.
Partner with clinical and operational leaders to develop corrective action plans, track progress, and achieve measurable improvements.
Facilitate staff education and training related to quality improvement, patient safety, and regulatory standards.
Regulatory Compliance & Accreditation
Ensure continuous compliance with The Joint Commission, CMS, and other applicable federal, state, and accrediting agencies.
Lead accreditation readiness activities, including surveys, audits, tracers, and mock surveys.
Maintain policies, procedures, and documentation to support regulatory compliance and best practices.
Serve as a key organizational resource for interpretation of regulatory standards and requirements.
Reporting & Governance
Prepare and present quality, patient safety, and performance reports to hospital leadership, medical staff committees, and the Governing Board.
Support leadership decision-making through data-driven insights and recommendations.
Leadership Responsibilities
People Leadership
Provide leadership, mentorship, and professional development for quality department staff.
Conduct performance evaluations, set goals, and provide ongoing feedback.
Ensure appropriate staffing levels and collaborate with leadership on workforce planning.
Strategic & Financial Management
Collaborate with executive leadership on departmental strategy, budget planning, and resource allocation.
Monitor departmental expenditures and ensure cost-effective delivery of services.
Evaluate and implement tools, systems, and technologies to improve quality outcomes and operational efficiency.
Collaboration & Communication
Partner with executive leaders, physicians, nursing leaders, and interdisciplinary teams to support organizational priorities.
Maintain awareness of industry trends, regulatory changes, and best practices in quality and patient safety.
Communicate effectively with stakeholders at all levels of the organization.
Qualifications
Education & Experience
Bachelor's degree in Nursing, Healthcare Administration, Public Health, or a related field required
OR
Seven (7) or more years of directly related experience in lieu of a bachelor's degree
Master's degree preferred
Minimum of 3-5 years of experience in healthcare quality, patient safety, or regulatory compliance
Prior leadership or management experience strongly preferred
Knowledge, Skills & Abilities
Strong leadership, organizational, and communication skills
Demonstrated ability to lead performance improvement initiatives across multidisciplinary teams
Advanced problem-solving, analytical, and critical-thinking skills
In-depth knowledge of healthcare quality standards, accreditation, and regulatory compliance
Ability to manage multiple priorities and meet deadlines in a fast-paced environment
Proficiency with Microsoft Office, Google platforms, healthcare information systems, and data analytics tools
Licenses & Certifications
CPHQ (Certified Professional in Healthcare Quality)
preferred
CPHRM (Certified Professional in Healthcare Risk Management)
preferred
What We Offer
Competitive compensation
Medical, Dental, Vision, and Life Insurance
Generous Paid Time Off (PTO) and Extended Illness Bank (EIB)
401(k) with employer match
Opportunities for career advancement
Rewards and recognition programs
Additional employee discounts and perks
INDLEAD
Equal Employment Opportunity
This organization does not discriminate in any way to deprive any person of employment opportunities or otherwise adversely affect the status of any employee because of race, color, religion, sex, sexual orientation, genetic information, gender identity, national origin, age, disability, citizenship, veteran status, or military or uniformed services, in accordance with all applicable governmental laws and regulations. In addition, the facility complies with all applicable federal, state and local laws governing nondiscrimination in employment. This applies to all terms and conditions of employment including, but not limited to: hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. If you are an applicant with a mental or physical disability who needs a reasonable accommodation for any part of the application or hiring process, contact the director of Human Resources at the facility to which you are seeking employment; Simply go to http://www.chs.net/serving-communities/locations/ to obtain the main telephone number of the facility and ask for Human Resources.
The Director of Quality is responsible for leading the organization's quality improvement, patient safety, and regulatory compliance programs. This role partners closely with executive leadership, medical staff, and department leaders to drive a culture of continuous improvement, ensure regulatory readiness, and improve clinical and operational outcomes. The Director of Quality oversees performance improvement initiatives, monitors quality metrics, and ensures delivery of safe, high-quality, patient-centered care across the organization.
Essential Responsibilities
Quality & Performance Improvement
Develop, implement, and oversee quality improvement and patient safety programs aligned with organizational goals and regulatory requirements.
Monitor, analyze, and trend quality, safety, and performance metrics to identify risks, gaps, and opportunities for improvement.
Lead and support Root Cause Analyses (RCA), Failure Modes and Effects Analysis (FMEA), and other performance improvement methodologies.
Partner with clinical and operational leaders to develop corrective action plans, track progress, and achieve measurable improvements.
Facilitate staff education and training related to quality improvement, patient safety, and regulatory standards.
Regulatory Compliance & Accreditation
Ensure continuous compliance with The Joint Commission, CMS, and other applicable federal, state, and accrediting agencies.
Lead accreditation readiness activities, including surveys, audits, tracers, and mock surveys.
Maintain policies, procedures, and documentation to support regulatory compliance and best practices.
Serve as a key organizational resource for interpretation of regulatory standards and requirements.
Reporting & Governance
Prepare and present quality, patient safety, and performance reports to hospital leadership, medical staff committees, and the Governing Board.
Support leadership decision-making through data-driven insights and recommendations.
Leadership Responsibilities
People Leadership
Provide leadership, mentorship, and professional development for quality department staff.
Conduct performance evaluations, set goals, and provide ongoing feedback.
Ensure appropriate staffing levels and collaborate with leadership on workforce planning.
Strategic & Financial Management
Collaborate with executive leadership on departmental strategy, budget planning, and resource allocation.
Monitor departmental expenditures and ensure cost-effective delivery of services.
Evaluate and implement tools, systems, and technologies to improve quality outcomes and operational efficiency.
Collaboration & Communication
Partner with executive leaders, physicians, nursing leaders, and interdisciplinary teams to support organizational priorities.
Maintain awareness of industry trends, regulatory changes, and best practices in quality and patient safety.
Communicate effectively with stakeholders at all levels of the organization.
Qualifications
Education & Experience
Bachelor's degree in Nursing, Healthcare Administration, Public Health, or a related field required
OR
Seven (7) or more years of directly related experience in lieu of a bachelor's degree
Master's degree preferred
Minimum of 3-5 years of experience in healthcare quality, patient safety, or regulatory compliance
Prior leadership or management experience strongly preferred
Knowledge, Skills & Abilities
Strong leadership, organizational, and communication skills
Demonstrated ability to lead performance improvement initiatives across multidisciplinary teams
Advanced problem-solving, analytical, and critical-thinking skills
In-depth knowledge of healthcare quality standards, accreditation, and regulatory compliance
Ability to manage multiple priorities and meet deadlines in a fast-paced environment
Proficiency with Microsoft Office, Google platforms, healthcare information systems, and data analytics tools
Licenses & Certifications
CPHQ (Certified Professional in Healthcare Quality)
preferred
CPHRM (Certified Professional in Healthcare Risk Management)
preferred
What We Offer
Competitive compensation
Medical, Dental, Vision, and Life Insurance
Generous Paid Time Off (PTO) and Extended Illness Bank (EIB)
401(k) with employer match
Opportunities for career advancement
Rewards and recognition programs
Additional employee discounts and perks
INDLEAD
Equal Employment Opportunity
This organization does not discriminate in any way to deprive any person of employment opportunities or otherwise adversely affect the status of any employee because of race, color, religion, sex, sexual orientation, genetic information, gender identity, national origin, age, disability, citizenship, veteran status, or military or uniformed services, in accordance with all applicable governmental laws and regulations. In addition, the facility complies with all applicable federal, state and local laws governing nondiscrimination in employment. This applies to all terms and conditions of employment including, but not limited to: hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. If you are an applicant with a mental or physical disability who needs a reasonable accommodation for any part of the application or hiring process, contact the director of Human Resources at the facility to which you are seeking employment; Simply go to http://www.chs.net/serving-communities/locations/ to obtain the main telephone number of the facility and ask for Human Resources.