Director of Quality in Hornell, New York at St. James Hospital

Job Title: Quality Director

Department: Quality

Reports To: Chief Medical Officer / Chief Nursing Officer

Job Type: Full-Time

The Director of Quality is responsible for the leadership, development, and oversight of hospital’s quality, patient safety, and regulatory compliance programs. This role ensures alignment with accreditation standards, including The Joint Commission, and drives performance improvement initiatives across the organization. The Director of Quality oversees the Infection Prevention program and works collaboratively with clinical and administrative leaders to promote a culture of safety, accountability, and continuous improvement.

• Lead the hospital-wide Quality Assessment and Performance Improvement (QAPI) program.
• Develop and implement hospital-wide quality and patient safety programs aligned with regulatory and accreditation standards (e.g., The Joint Commission, CMS, OSHA).
• Utilize data analytics and performance metrics to drive continuous quality improvement (CQI) initiatives.
• Oversee root cause analyses (RCAs), corrective action plans, and performance improvement activities.
• Report quality outcomes and trends to executive leadership and governing bodies.
• Chair and/or participate in key hospital committees related to quality, patient safety, and performance improvement.

• Provide oversight and leadership to the Infection Preventionist and infection control program.
• Ensure compliance with infection prevention standards and evidence-based practices. Lead the hospital's infection prevention and control (IPC) program, ensuring adherence to CDC, WHO, and regulatory guidelines.
• Monitor hospital-acquired infections (HAIs) and implement strategies to reduce infection risks.
• Support education and initiatives to reduce infection risks across the organization.

• Ensure hospital compliance with all applicable state, federal, and accreditation agencies, including CMS, The Joint Commission, and OSHA.
• Lead preparation for accreditation and regulatory surveys, audits, and inspections.
• Develop and maintain policies and procedures to align with evolving healthcare standards.
• Serve as the hospital’s primary resource for accreditation readiness and compliance.

• Partner with medical staff, nursing, and department leaders to advance quality and patient safety goals.
• Chair or participate in quality and patient safety committees.
• Provide guidance and education on quality improvement methodologies and best practices.
• Foster a culture of accountability, transparency, and high reliability.

• Bachelor's Degree in Nursing (BSN), Healthcare Administration, or related field required; Master's Degree (MSN, MHA, MPH, or MBA) strongly preferred.
• Minimum of 5-7 years of progressive leadership experience in hospital quality, case management, infection prevention, or related areas.
• Extensive experience in regulatory compliance, accreditation processes, and performance improvement methodologies (e.g., Lean, Six Sigma, PDSA cycles).
• Experience working with EHR systems, clinical analytics, and data-driven decision-making.

• Certified Professional in Healthcare Quality (CPHQ)
• Certified Case Manager (CCM) or Accredited Case Manager (ACM)
• Certified in Infection Control (CIC)
• Lean Six Sigma Green/Black Belt (preferred)

• Strong leadership, communication, and collaboration skills.
• Expertise in data analysis, reporting, and quality improvement methodologies.
• Deep understanding of regulatory and compliance standards in healthcare.
• Ability to lead multidisciplinary teams and drive culture change.
• Strategic thinking with the ability to execute hospital-wide initiatives effectively.