Director of Quality, Safety, & Regulatory Compliance in Shelton, Washington at Mason Health

Director of Quality, Patient Safety and Regulatory Compliance:This 1.0 FTE/Full-Time position is scheduled to work an 8-hour day shift.

Compensation: Exempt $56.72 /HR — $81.03/HR. Placement within this range is based on applicable experience.

Benefits:

At Mason Health, we are committed to providing our employees with a comprehensive benefits package that supports both your professional growth and personal well-being. Whether you are a part-time or full-time member:

Health & Wellness Benefits:

• Medical, Dental & Vision Insurance – With employer paid premiums for full-time employees
• Mental Health & Wellness Resources – Access to our Employee Assistance Program (EAP), Talkspace, and the Calm App.
• Life Insurance
• Short & Long-Term Disability Insurance

Financial Benefits:

• Retirement/Deferred Compensation Plans – Mason Health contributes 8% of your compensation every pay period when you contribute at least 5%.
• Flexible Spending Account (FSA)
• Tuition Assistance Program
• Approved by the Health Resources and Services Administration (HRSA) for student loan repayment programs.

Time Off & Work-Life Balance:

• Generous Paid Time Off (PTO) – Accrue up to 8 hours of PTO every bi-weekly pay period, starting with 5 weeks of PTO and increasing to 7+ weeks after 3 years.

Exciting Incentive:

• Employee Referral Program – Earn up to $7,500 depending on the role.

Job Summary:

The Director of Quality, Patient Safety & Regulatory Compliance provides strategic and operational leadership for the organization’s quality, patient safety, performance improvement, regulatory compliance, accreditation readiness, and related programs. The Director leads the development, implementation, and evaluation of the organization-wide Quality and Patient Safety Plan; advances a culture of safety, high reliability, continuous improvement, and accountability; and ensures ongoing compliance with applicable federal, state, and accreditation requirements.

The Director partners with executive leadership, medical staff, clinical and operational leaders, and the Board to translate quality and safety data into measurable improvement in clinical outcomes, patient safety, regulatory performance, and organizational reliability. The position provides leadership oversight for assigned functions, including Employee Health, Infection Prevention and Control, Interpreter Services, and the Quality Office.

Essential Duties and Responsibilities:

1. Strategic Quality Leadership: Leads development, implementation, and evaluation of the organization-wide Quality and Patient Safety Plan aligned with strategic priorities and measurable outcomes.
2. Patient Safety & High Reliability: Leads patient safety strategy, safety culture, event analysis, RCA/FMEA, Just Culture, and initiatives to reduce preventable harm.
3. Regulatory & Accreditation: Maintains continuous readiness for DNV, TJC, CMS, DOH, and other applicable regulatory/accrediting requirements; leads surveys and corrective actions.
4. Performance Improvement & Analytics: Uses data, benchmarks, dashboards, and improvement science to identify variation and drive sustained improvement.
5. Quality Measurement & Reporting: Oversees data integrity, external reporting, quality measures, and organizational performance monitoring.
6. Clinical Partnership: Partners with medical staff, nursing, clinical, and operational leaders to improve outcomes and standardize evidence-based practices.
7. Governance & Executive Communication: Reports quality, safety, regulatory risk, and improvement performance to senior leadership, medical staff committees, and Board/governance bodies.
8. Departmental Leadership: Provides strategic and administrative oversight for assigned departments/programs, including Employee Health, Infection Prevention and Control, Interpreter Services, and Quality.
9. People & Financial Leadership: Manages staffing, talent development, succession, budgets, and resources for assigned functions.
10. Continuous Improvement Culture: Advances Lean/Kaizen, high reliability, learning systems, patient/family engagement, and a culture of safety and accountability.
11. Other duties as assigned.

Required Education and Experience:

1. Bachelor's degree in Nursing, Healthcare Administration, Public Health, Business Administration, or a related field required. Master's degree in Nursing, Healthcare Administration, Public Health, Business Administration, or a related field preferred.
2. Minimum of seven (7) years of progressively responsible healthcare experience in quality, patient safety, performance improvement, regulatory compliance/accreditation, or a related field.
3. Minimum of three (3) years of formal leadership or management experience.
4. Hospital and/or integrated ambulatory healthcare experience,

Required Licenses, Certifications and/or Registrations:

1. Current RN license in the state of Washington, strongly preferred. Relevant quality related experience may be considered in lieu of licensure.
2. CPHQ and/or Certified Professional in Patient Safety or must be obtained within two years.
3. Formal Lean or Lean Six Sigma certification/training preferred; the required level of organizational Lean training must be completed within two years of hire.

Required Knowledge, Skills and Abilities:

1. Analytical & Data Management Skills: Demonstrated ability to analyze, interpret, and communicate complex clinical, quality, safety, and operational data; identify trends and opportunities for improvement; develop meaningful dashboards and performance metrics; and translate findings into actionable strategies. Experience with electronic health records (EHRs), quality reporting systems, patient safety/event reporting systems, data visualization tools, and healthcare analytics platforms preferred.
2. Performance Improvement Expertise: Demonstrated expertise in performance improvement, healthcare analytics, and achieving measurable organizational outcomes through the use of evidence-based practices and data-driven decision-making.
3. Improvement Methodologies: Demonstrated proficiency in recognized performance improvement methodologies, including Lean, Lean Six Sigma, PDSA, or other continuous improvement frameworks.
4. Technology Proficiency: Proficient in Microsoft Office Suite and other current technology. Ability to quickly learn and effectively utilize electronic health records, quality management systems, and other software and equipment necessary to support departmental operations.
5. Documentation & Record Management: Ability to develop, implement, and maintain accurate documentation, records, policies, and reporting processes in accordance with regulatory, accreditation, and organizational standards.
6. Collaboration & Relationship Building: Ability to establish and maintain effective working relationships with providers, leaders, staff, patients, caregivers, and external partners. Demonstrated leadership, facilitation, delegation, coaching, and team-building skills that promote collaboration and organizational success.
7. Communication Skills: Excellent written and verbal communication skills with the ability to effectively present complex information, facilitate discussions, and tailor communication to diverse audiences.
8. Leadership & Influence: Demonstrated ability to lead cross-functional initiatives, facilitate change, educate and mentor others, build consensus, and influence organizational improvement without direct authority.
9. Critical Thinking & Organization: Ability to work independently while managing multiple priorities, exercising sound judgment, solving complex problems, and maintaining a high level of organization, accuracy, and accountability.

Mason Health practices equal employment opportunity towards all workforce members and applicants for employment. Mason Health does not engage in or tolerate any discrimination in the workplace prohibited by applicable local, state, or federal law. Specifically, no workforce member will be discriminated against on the basis of their race, color, sex/gender (including pregnancy), sexual orientation, religion/creed, age, disability, marital or veteran status, national origin, genetic information, or any other characteristic protected by applicable state or federal law.