Quality Director at Lutheran Health Network

Job Summary

The Director, Quality is responsible for developing, implementing, and overseeing quality improvement and patient safety programs within the facility. This role ensures compliance with regulatory standards and works closely with hospital leadership and department heads to promote a culture of continuous improvement. The Director monitors quality metrics, coordinates performance improvement initiatives, and provides guidance to ensure high-quality, patient-centered care across the facility.

Essential Functions

• Develops and oversees quality and performance improvement initiatives to meet regulatory standards and improve patient care outcomes.
• Monitors quality metrics and performance data, analyzing trends and identifying areas for improvement across clinical and operational areas.
• Leads and supports teams in conducting root cause analyses, Failure Modes and Effects Analysis (FMEA), and other quality methodologies.
• Collaborates with department leaders to develop action plans, track progress, and achieve performance targets related to quality and patient safety.
• Facilitates training and education programs for staff on quality improvement practices, patient safety standards, and regulatory requirements.
• Ensures compliance with The Joint Commission, Centers for Medicare & Medicaid Services (CMS), and other accrediting and regulatory agencies.
• Prepares and presents quality and performance reports to hospital administration, committees, and the Governing Board to support informed decision-making.
• Performs other duties as assigned.
• Maintains regular and reliable attendance.
• Complies with all policies and standards.
  
  

Leadership Responsibilities

• Supervision and Staff Management
• Provides leadership, mentorship and professional development opportunities for departmental staff.
• Schedules employees to ensure effective use of resources. Consults with leadership on any potential staffing issues.
• Conducts performance evaluations, sets goals and provides feedback to staff on their performance and development.
• Strategic Planning and Financial Oversight
• Collaborates with hospital leadership to set the strategic direction for the department, including budgeting, resource allocation and long-term planning.
• Monitors expenditures, ensuring cost-effective delivery of services.
• Evaluates and implements new technologies to enhance operational efficiency.
• Develops and implements departmental policies and procedures and protocols to optimize quality and overall efficiencies.
• Quality Assurance and Regulatory Compliance
• Ensures compliance with all relevant regulatory bodies. May oversee the accreditation process with relevant agencies ensuring that services meet or exceed industry standards.
• Participates in audits, inspections and accreditation processes as applicable.
• Follows established quality control practices to ensure accuracy, consistency and safety.
• Collaboration and Communication
• Works closely with leadership teams to coordinate and improve service delivery.
• Stays up-to-date with industry advancements, new technologies, and regulatory changes.
• Staff Responsibilities
• May work in a staff role, when required. Ensures that duties and responsibilities are fulfilled while meeting all competencies established for that job.
  

Qualifications

• Bachelor's Degree in relevant field required or
• Seven (7) plus years of direct experience in lieu of a Bachelor's degree required
• Master's Degree preferred
• 3-5 years of experience in closely related field with Bachelor's degree required
• 3-5 years of previous leadership experience preferred
  
  

Knowledge, Skills And Abilities

• Strong leadership, organizational, and communication skills.
• Ability to collaborate with interdisciplinary teams and manage cross-functional relationships.
• Foster a positive work environment that promotes teamwork, professionalism, and continuous improvement.
• Communicate effectively with leadership, team members, and stakeholders.
• Ability to work effectively with others, delegate responsibilities, and independently manage tasks while meeting established deadlines.
• Problem-solving and critical thinking skills.
• In depth knowledge of industry best practices and regulatory compliance (if applicable).
• Strong organizational and time management skills.
• Proficiency with Google and Microsoft platforms, healthcare software systems, and data analysis tools.
  
  

Licenses and Certifications

• CPHQ - Certified Professional in Healthcare Quality preferred or
• CPHRM - Certified Professional in Healthcare Risk Management preferred
  
  

What We Offer

• Competitive Pay - Medical, Dental, Vision, & Life Insurance
• Generous Paid Time Off (PTO) and Extended Illness Bank (EIB)
• Matching 401(k)
• Opportunities for Career Advancement
• Rewards and Recognition Programs & Additional Discounts and Perks
  
  

INDLEAD