LaFollette Medical Center
Director of Quality - Healthcare
La Follette
,
TN
Full Time
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
People Leadership
Education & Experience
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.
- 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.
- 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.
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.
- 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.
- 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.
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
- 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
- CPHQ (Certified Professional in Healthcare Quality) preferred
- CPHRM (Certified Professional in Healthcare Risk Management) preferred
- 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