Director - Quality Management & Regulatory Affairs

A Brief Overview

The Director of Quality Management and Regulatory Affairs is responsible for oversight and direction of accreditation, regulatory, and licensing across Stanford Health Care. This includes continuous readiness plans, document management, peer review process, and care improvement committee responsibilities. Reporting to the Executive Director for Quality, Patient Safety & Infection Prevention, the Director collaborates with cross‑functional leaders to develop and implement the quality assessment and performance improvement plan (QAPI). The key areas of responsibility include development and implementation of the tactics and communication plans which ensure that the organization is continually prepared for reliable care in accordance with accreditation, federal and state regulatory requirements.
What you will do

Serve as contact for accreditation, certification, and regulatory activities, including survey preparation and readiness assessments for all licensed care areas.
Assist with interpretation of standards and regulations and serve as the point of contact for accreditation bodies.
Establish and implement organizational regulatory guidelines and planning.
Coordinate accreditation activities through the organization, ensure continuous readiness for surveys, and work with senior leadership to target interventions to improve a culture of continuous patient readiness.
Responsible for overseeing the organization’s administrative manual and policy and procedure processes.
Plan and provide oversight for the peer review staff and management in support of the Chief of Staff and in alignment with medical staff bylaws.
Ensure compliance with peer review standards in collaboration with the Chief of Staff and Executive Director for Quality, Patient safety, and Infection Prevention.
Plan and manage the analysis, summaries, and reports regarding accreditation activities and performance to organizational leadership.
Apply project management, people management, and communication skills to lead the continuous readiness plan creation and implementation.
Oversee the equitable distribution of accreditation and regulatory team resources, ensuring teams are integrated, visible, and effectively contribute to the organization's strategic objectives.
Balance resource allocation to maximize impact and efficiency.
Create a working environment that supports ongoing professional growth and development of all staff, high morale, and optimal job satisfaction.
Lead, mentor, coach, and inspire a team of quality professionals through a positive, team‑first attitude.
Employees must perform all duties and responsibilities in accordance with the C‑I‑CARE Standards of the health system.
Education Qualifications

Master’s degree in a work‑related field/discipline from an accredited college or university required. Master’s in Healthcare Quality, Health Policy, Public Health, Health Services Administration, Business Administration or equivalent.
Experience Qualifications

Five years of progressively responsible and directly related work experience working with senior executive leadership. Health system operations experience preferred.
Required Knowledge, Skills and Abilities

Demonstration of effective verbal and written communication skills.
Exceptional leadership, communication, and relationship‑building skills, with a strong emphasis on emotional intelligence.
Demonstrated ability to navigate and influence across all levels of an organization, translating strategic vision into tangible outcomes.
Ability to interact effectively in a complex organization and in ambiguous situations; ability to manage sensitive situations with exceptional judgment and discretion.
Knowledge of governmental and other regulatory standards, requirements, and guidelines, specifically, Joint Commission, CMS Conditions of Participation, Title 22, California Business & Professions code, California Health and Safety Code.
Knowledge of principles and practices of organization, administration, fiscal and personnel management.
Knowledge of local, state and federal regulatory requirements related to the functional area.
Knowledge of computer systems and software used in functional area, including Electronic Health Records (EHR).
Experience with Microsoft Office Products (including Word, Excel, PowerPoint) and Visio.
Experience with tracing/auditing, OPPE/FPPE, Peer review, and policy management electronic systems.
Demonstrated ability to manage, organize, prioritize and adapt to changing priorities.
Ability to provide leadership and influence others.
Ability to foster effective working relationships and build consensus.
Ability to mediate and resolve complex problems and issues.
Licenses and Certifications

CPHQ - Health Care Quality Certification preferred.
PMP - Project Management Professional preferred.
Six Sigma Black Belt Certification (CSSBB) preferred.
State board licensure in nursing, social work, physical therapy, respiratory, pharmacy, or profession of relevance preferred.
Equal Opportunity Employer

Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non‑discrimination in all of its policies and practices. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.
Base Pay Scale

Generally starting at $89.01 - $117.94 per hour. The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.

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