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Overview
Approximate Pay Range: $138,100 - $200,000/year. Eligible for an in-state or out-of-state relocation bonus. Employer:
St. Charles Health System Job Title:
Director of Quality Management Reports To:
Chief Nurse Executive/Chief Clinical Officer Department:
Quality Management Date Last Reviewed:
October 2025 Organization Context
Our Vision:
Creating Americas healthiest community, together Our Mission:
In the spirit of love and compassion, better health, better care, better value Our Values:
Accountability, Caring Teamwork and Safety Department Summary
The Quality Management (QM) department provides essential services to St. Charles Health System (SCHS) across the continuum of care, including quality improvement expertise and support; data analysis and reporting; regulatory affairs, accreditation and licensing expertise, maintain infection prevention and control; support; emergency preparedness; policy and document library management and support. Position Overview
The Director of Quality Management provides oversight and direction to the SCHS quality and safety programs to achieve clinical quality performance improvement, mortality review and reduction, quality assessments, quality data analysis and reporting (including external quality reporting and clinical registries for benchmarking and reporting). This leader oversees regulatory compliance, accreditation status, and infection prevention. Collaborates with Risk Management & Patient Safety, and Environment of Care to improve and maintain a safe environment for patients and caregivers. This role supports clinical care and support functions to enhance safety and experience for patients, families, caregivers, and the organization. This position manages caregivers in the Quality Management Department. Essential Functions and Duties
Partners with campus executive leadership teams and departments to ensure that the quality and safety programs effectively measure, assess, and continuously improve the care and safety of services provided. Serves as a key partner for Nursing, Medical Staff, and administrative leaders to achieve System Quality Key Performance Indicators (KPIs) and advance the vision for clinical excellence and the effective use of resources through continuous quality improvement. In collaboration with executive leadership, sets goals and strategic direction for units within the QM department and oversees work products for Regulatory Affairs, Accreditation, & Safety, Quality Data, Quality Improvement, Infection Prevention. Develops, implements, and monitors the QM annual plan and budgets toward achieving System Quality KPIs. Assists and collaborates with local leadership at each site to create written quality assurance improvement plans (QAPI) on a yearly basis. Contributes to ongoing monitoring of the plan and progress toward goals. Promotes a Culture of Excellence and non-punitive response to reporting. Keeps up to date with new and revised state and federal statutes, regulations, and accreditation policies related to patient care. Reviews and evaluates related policies and procedures and recommends revisions as needed. Creates for approval new policies as needed. Proactively evaluates areas of organizational clinical quality based on internal assessment and external benchmarking; Clinical Quality Data Analytics and Reporting and implements strategies and policies which promote evidence-based care. Oversees Infection Prevention and Control Plan; maintains annual risk assessment and program plan; oversees Safety Audits and required regulatory audits for all levels of care. Prepares quality management reports for leadership with key performance indicators, strategies, and barriers to achieving targets and presents to Medical Executive Committee, Clinical Leadership Council and the Board Safety and Quality Committee. Advises Executive Leadership and Legal & Risk on issues impacting quality management and process improvement opportunities and initiatives. In coordination with Legal and Compliance, serves as liaison to external regulatory agencies for patient and physician reporting, event investigation and response (including Oregon Health Authority). Supports hospital executive teams to develop, implement, and monitor programs, policies, and procedures according to SCHS, OSHA, Joint Commission, local, state, and federal standards and statutes. Manages the organization\'s accreditation, regulation, and licensing activities by communicating programs and processes, preparing for reporting, surveys, and inspections, and by developing assessments, audits, and action plan responses (includes TJC, CMS, CLIA, OAR, OSHA, DPSST, etc.). Ensures SCHS policies and procedures are accurate, current, and consistent across the system. Collaborates with Business Intelligence, IT, hospital and clinic leadership, and medical staff leadership to ensure performance data is analyzed, communicated, and routinely provided to achieve System Quality KPIs. Engages and supports leadership in developing process and quality improvements based on best practice, federal and state standards, laws, and regulations, in partnership with Lean Improvement Office and clinical/support operations. Participates in regional and statewide quality improvement/patient safety initiatives and represents SCHS interests (e.g., Central Oregon\'s CCO, Pacific Source, OAHHS, NW Patient Safety Collaborative). Staffs and actively participates in Clinical Leadership Council and the Safety and Quality Committee of the Board of Directors. Educates and communicates effectively with providers, caregivers, and others about safety events, in partnership with Performance Improvement and Safety regarding response plans. Supports and participates in activities that promote professional growth and development across the QM department. Hires, directs, coaches, and monitors the performance of all direct reports to develop and maintain a high-performance team that meets organizational and department goals. Monitors and ensures all direct reports are current with compliance and safety requirements. Implements and manages all organizational safety directives and goals. Provides and oversees teams delivery of customer service that is timely, efficient, and accurate, while maintaining professionalism and confidentiality. Complies with all applicable laws, regulations, policies, and procedures, supporting the health system\'s corporate integrity efforts by acting ethically and reporting known or suspected violations. Supports the vision, mission, and values of the organization and Lean principles of continuous improvement. May perform additional duties of similar complexity within SCHS as required or assigned. Education
Required:
Masters degree in healthcare administration, public health administration, nursing, or other health related field. Licensure/Certification/Registration
Required:
Lean leader training. Valid Oregon driver\'s license and ability to meet SCHS driving requirements. Ability to travel to business functions/trainings/meetings and all SCHS worksites. Certified Professional in Healthcare Quality (CPHQ) or completion within one year of hire. Experience
Required:
Minimum of seven (7) years of quality improvement experience in a healthcare setting. Three (3) years of experience in a management role within healthcare operations, including regulatory, patient safety and/or clinical risk issues. Demonstrated knowledge of governmental and other regulatory standards and guidelines related to healthcare quality improvement (e.g., Joint Commission, AHRQ, CMS, IHI, NQF). Personal Protective Equipment
Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely. Physical Requirements
Continually (75% or more): Use of clear and audible speaking voice and the ability to hear normal speech level. Frequently (50%): Sitting, standing, walking, lifting 1-10 pounds, keyboard operation. Occasionally (25%): Bending, climbing stairs, reaching overhead, carrying/pushing, or pulling 1-10 pounds, grasping/squeezing. Rarely (10%): Stooping/kneeling/crouching, lifting, carrying, pushing, or pulling 11-15 pounds, operation of a motor vehicle. Never (0%): Climbing ladder/stepstool, lifting/carrying/pushing, or pulling 25-50 pounds, ability to hear whispered speech level. Exposure to Elemental Factors: Never (0%): Heat, cold, wet/slippery area, noise, dust, vibration, chemical solution, uneven surface. Blood-Borne Pathogen (BBP) Exposure Category: No Risk for Exposure to BBP Schedule Weekly Hours: 40 Caregiver Type: Regular Shift: First Shift (United States of America) Is Exempt Position?: Yes Job Family: DIRECTOR Scheduled Days of the Week: Monday-Friday Shift Start & End Time:
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Approximate Pay Range: $138,100 - $200,000/year. Eligible for an in-state or out-of-state relocation bonus. Employer:
St. Charles Health System Job Title:
Director of Quality Management Reports To:
Chief Nurse Executive/Chief Clinical Officer Department:
Quality Management Date Last Reviewed:
October 2025 Organization Context
Our Vision:
Creating Americas healthiest community, together Our Mission:
In the spirit of love and compassion, better health, better care, better value Our Values:
Accountability, Caring Teamwork and Safety Department Summary
The Quality Management (QM) department provides essential services to St. Charles Health System (SCHS) across the continuum of care, including quality improvement expertise and support; data analysis and reporting; regulatory affairs, accreditation and licensing expertise, maintain infection prevention and control; support; emergency preparedness; policy and document library management and support. Position Overview
The Director of Quality Management provides oversight and direction to the SCHS quality and safety programs to achieve clinical quality performance improvement, mortality review and reduction, quality assessments, quality data analysis and reporting (including external quality reporting and clinical registries for benchmarking and reporting). This leader oversees regulatory compliance, accreditation status, and infection prevention. Collaborates with Risk Management & Patient Safety, and Environment of Care to improve and maintain a safe environment for patients and caregivers. This role supports clinical care and support functions to enhance safety and experience for patients, families, caregivers, and the organization. This position manages caregivers in the Quality Management Department. Essential Functions and Duties
Partners with campus executive leadership teams and departments to ensure that the quality and safety programs effectively measure, assess, and continuously improve the care and safety of services provided. Serves as a key partner for Nursing, Medical Staff, and administrative leaders to achieve System Quality Key Performance Indicators (KPIs) and advance the vision for clinical excellence and the effective use of resources through continuous quality improvement. In collaboration with executive leadership, sets goals and strategic direction for units within the QM department and oversees work products for Regulatory Affairs, Accreditation, & Safety, Quality Data, Quality Improvement, Infection Prevention. Develops, implements, and monitors the QM annual plan and budgets toward achieving System Quality KPIs. Assists and collaborates with local leadership at each site to create written quality assurance improvement plans (QAPI) on a yearly basis. Contributes to ongoing monitoring of the plan and progress toward goals. Promotes a Culture of Excellence and non-punitive response to reporting. Keeps up to date with new and revised state and federal statutes, regulations, and accreditation policies related to patient care. Reviews and evaluates related policies and procedures and recommends revisions as needed. Creates for approval new policies as needed. Proactively evaluates areas of organizational clinical quality based on internal assessment and external benchmarking; Clinical Quality Data Analytics and Reporting and implements strategies and policies which promote evidence-based care. Oversees Infection Prevention and Control Plan; maintains annual risk assessment and program plan; oversees Safety Audits and required regulatory audits for all levels of care. Prepares quality management reports for leadership with key performance indicators, strategies, and barriers to achieving targets and presents to Medical Executive Committee, Clinical Leadership Council and the Board Safety and Quality Committee. Advises Executive Leadership and Legal & Risk on issues impacting quality management and process improvement opportunities and initiatives. In coordination with Legal and Compliance, serves as liaison to external regulatory agencies for patient and physician reporting, event investigation and response (including Oregon Health Authority). Supports hospital executive teams to develop, implement, and monitor programs, policies, and procedures according to SCHS, OSHA, Joint Commission, local, state, and federal standards and statutes. Manages the organization\'s accreditation, regulation, and licensing activities by communicating programs and processes, preparing for reporting, surveys, and inspections, and by developing assessments, audits, and action plan responses (includes TJC, CMS, CLIA, OAR, OSHA, DPSST, etc.). Ensures SCHS policies and procedures are accurate, current, and consistent across the system. Collaborates with Business Intelligence, IT, hospital and clinic leadership, and medical staff leadership to ensure performance data is analyzed, communicated, and routinely provided to achieve System Quality KPIs. Engages and supports leadership in developing process and quality improvements based on best practice, federal and state standards, laws, and regulations, in partnership with Lean Improvement Office and clinical/support operations. Participates in regional and statewide quality improvement/patient safety initiatives and represents SCHS interests (e.g., Central Oregon\'s CCO, Pacific Source, OAHHS, NW Patient Safety Collaborative). Staffs and actively participates in Clinical Leadership Council and the Safety and Quality Committee of the Board of Directors. Educates and communicates effectively with providers, caregivers, and others about safety events, in partnership with Performance Improvement and Safety regarding response plans. Supports and participates in activities that promote professional growth and development across the QM department. Hires, directs, coaches, and monitors the performance of all direct reports to develop and maintain a high-performance team that meets organizational and department goals. Monitors and ensures all direct reports are current with compliance and safety requirements. Implements and manages all organizational safety directives and goals. Provides and oversees teams delivery of customer service that is timely, efficient, and accurate, while maintaining professionalism and confidentiality. Complies with all applicable laws, regulations, policies, and procedures, supporting the health system\'s corporate integrity efforts by acting ethically and reporting known or suspected violations. Supports the vision, mission, and values of the organization and Lean principles of continuous improvement. May perform additional duties of similar complexity within SCHS as required or assigned. Education
Required:
Masters degree in healthcare administration, public health administration, nursing, or other health related field. Licensure/Certification/Registration
Required:
Lean leader training. Valid Oregon driver\'s license and ability to meet SCHS driving requirements. Ability to travel to business functions/trainings/meetings and all SCHS worksites. Certified Professional in Healthcare Quality (CPHQ) or completion within one year of hire. Experience
Required:
Minimum of seven (7) years of quality improvement experience in a healthcare setting. Three (3) years of experience in a management role within healthcare operations, including regulatory, patient safety and/or clinical risk issues. Demonstrated knowledge of governmental and other regulatory standards and guidelines related to healthcare quality improvement (e.g., Joint Commission, AHRQ, CMS, IHI, NQF). Personal Protective Equipment
Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely. Physical Requirements
Continually (75% or more): Use of clear and audible speaking voice and the ability to hear normal speech level. Frequently (50%): Sitting, standing, walking, lifting 1-10 pounds, keyboard operation. Occasionally (25%): Bending, climbing stairs, reaching overhead, carrying/pushing, or pulling 1-10 pounds, grasping/squeezing. Rarely (10%): Stooping/kneeling/crouching, lifting, carrying, pushing, or pulling 11-15 pounds, operation of a motor vehicle. Never (0%): Climbing ladder/stepstool, lifting/carrying/pushing, or pulling 25-50 pounds, ability to hear whispered speech level. Exposure to Elemental Factors: Never (0%): Heat, cold, wet/slippery area, noise, dust, vibration, chemical solution, uneven surface. Blood-Borne Pathogen (BBP) Exposure Category: No Risk for Exposure to BBP Schedule Weekly Hours: 40 Caregiver Type: Regular Shift: First Shift (United States of America) Is Exempt Position?: Yes Job Family: DIRECTOR Scheduled Days of the Week: Monday-Friday Shift Start & End Time:
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