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Quality Senior Director

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Job Information:

Job Number: NGC 772
Location: Maryland

Senior Director Quality Management

Salary Range: $150,000 - $180,000

Relocation Assistance

Location: Maryland



This is for a 230 bed hospital

The Senior Director of Quality Management is an administrative position and has direct responsibility for Risk Management, Quality, Infection Control/Prevention, Patient Safety, and Joint Commission/CMS/DHMH regulatory functions.

  • Reports to VP Medical Affairs

  • 11 FTEs

  • Coordinates and provides leadership of the patient safety, quality, performance improvement, infection prevention and risk management functions.

  • Assures regulatory compliance through developing and implementing educational programs and audit processes for Joint Commission accreditation and CMS condition of participation compliance.

  • Oversees the development and implementation of appropriate training programs pertaining to quality, performance improvement, patient safety and risk management.

  • Ensures compliance with Joint Commission standards and CMS conditions of participation on an ongoing basis. Provides leadership and direction to others.

  • Leads survey activities related to regulatory compliance, and ensures follow up activities required.

  • Works with Executive leadership, department heads and nursing directors in the development of processes to systematically monitor, evaluate and improve the quality of care rendered in accordance with accepted standards and evidence based criteria. This includes the development of indicators and criteria.

  • Serves as the administrative leader for the Medical Quality Committee of the Board of Trustees and the Quality and Patient Safety Committee of the hospital.

  • Collaborates closely with the medical staff office leadership and members of the professional staff to effectively implement patient safety, performance improvement, infection control/prevention, and risk management programs. Supports the Professional staff in the implementation of Peer Review and quality review activities.

  • Provides direction for participation in national databases of quality, to include assuring data integrity including but not limited to: NSQIP, ACC, STS, and Get with the Guidelines.

  • Responsible for the Performance Improvement Plan.

  • Responsible for the Risk Management System, and oversees the event reporting system through the risk management staff.

  • Develops departmental goals and objectives that support the primary functions of the hospital and reflect areas of responsibility.

  • Responsible for securing budget approval for functions under management responsibilities including all new programs. Develops budgets for performance improvement, joint commission readiness, risk management programs, infection control/prevention, patient safety and quality. Ensures adequate staffing in areas of responsibility.

  • Responsible for all human resource functions in areas of responsibility including recruiting, evaluating and the disciplinary process. Orients new employees; evaluates for competencies and performance.

    Educational Requirements:

  • Bachelor of Science Degree in Nursing

  • Current Maryland Licensure as Registered Nurse


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