DIRECTOR OF QUALITY, RIVER OAKS HOSPITAL

The Director of Quality is responsible for leadership and strategic direction, oversight, and coordination of quality functions that may include This role ensures compliance with regulatory standards, promotes a culture of continuous improvement, and partners with clinical and administrative leaders to enhance patient outcomes and organizational excellence.

This position regularly collaborates with medical staff, hospital leadership, and outside agents to collect and analyze hospital data, implement strategies and manage outcomes to provide cost-effective, quality safe healthcare delivery.

DUTIES AND RESPONSIBILITIES

• Serve as a liaison with executive leadership, medical staff, and department leaders regarding quality, safety, and performance improvement priorities
• Oversee the design, implementation, and evaluation of the organizations quality and performance improvement programs.
• Ensure compliance with applicable healthcare laws, regulatory requirements, accreditation standards, and reporting obligations (CMS, state, and other regulatory agencies).
• Direct data collection, analysis, and reporting for quality indicators, patient safety metrics, and performance improvement initiatives.
• Monitor patient flow and quality-related processes to identify opportunities to reduce delays and improve care delivery without compromising safety or outcomes.
• Maintain schedules and staffing plans for the Quality Department, ensuring adequate coverage to meet organizational needs.
• Communicates effectively with all levels of staff, physicians, and external groups including regulators, payors, and accrediting bodies.

REQUIREMENTS

• RN Registered Nurse - Texas State Licensure - preferred
• Five years of management experience in a healthcare environment.
• Three years of experience in hospital Quality/Performance Improvement with demonstrated experience in understanding and executing performance improvement concepts and activities and regulatory surveys preparation.
• Proficiency with quality data systems, EHRs, reporting tools, and data visualization platforms.
• MS Office, Word, Excel, PPT, Outlook
• Basic Life Support (BLS) American Heart Assoc.
• Extensive knowledge of regulatory and accreditation agency requirements that impact department.
• Skill in use of clinical and operational outcomes and comparative performance benchmark databases.
• Effective communication skillsstrong written communications and platform presentation abilities.
• Comprehensive understanding of healthcare regulations, accreditation standards, and compliance requirements.
• Skilled in applying quality management principles, patient safety practices, and performance improvement methodologies.

EDUCATION

CERTIFICATION, LICENSURE

• Nationally recognized certification in quality, patient safety, regulatory, risk, or related area, preferred

KNOWLEDGE SKILS AND ABILITIES

• Excellent oral and written communication skills, with strong attention to detail.
• Ability to manage crises and ensure all policies and protocols are followed to manage hospital/clinical risk.
• Demonstrates the ability to interact with others in a way that gives them confidence in ones intentions and those of the organization.
• Demonstrates leadership qualities and critical thinking through self-direction initiative and effective interpersonal skills and oral/written communication skills.

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