St. Charles Health System
Approximate Pay Range: $138,100 - $200,000/year
Eligible for an in-state or out-of-state relocation bonus.
ST. CHARLES HEALTH SYSTEM
JOB DESCRIPTION
TITLE:
Director of Quality Management
REPORTS TO POSITION:
Chief Nurse Executive/Chief Clinical Officer
DEPARTMENT:
Quality Management
DATE LAST REVIEWED:
October 2025
OUR VISION:
Creating America's 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 St. Charles Health System quality and safety programs to achieve the following: 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 also 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 is critical in the support of clinical care and support functions to enhance the 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 the 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 (KPI's) and advance the vision for clinical excellence and the effective use of resources through continuous quality improvement.
In collaboration with executive leadership, set goals and strategic direction for units within the QM department and oversees work product 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 Key Performance Indicators (KPI's) goals and objectives. Assist and collaborate with local leadership at each site to create written quality assurance improvement plan (QAPI) on a yearly basis. In addition, contribute to ongoing monitoring of the plan and progress towards 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.
Responsible for oversight and collaboration of Infection Prevention and Control Plan; maintain annual risk assessment and program plan, oversee Safety Audits and required regulatory audits for all levels of care.
Prepares quality management reports for leadership, with key performance indicators with 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, the Legal & Risk on issues impacting quality management and process improvement opportunities and initiatives.
In coordination with the Legal and Compliance Departments, as applicable, serves as liaison to external regulatory agencies for purposes of patient and physician reporting, event investigation and response, including Oregon Health Authority,
Supports the hospital executive teams and others, 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 the various programs and processes, preparing the organization for reporting, surveys, and inspections, and by developing assessments, audits, and action plan responses. Includes TJC, CMS, CLIA, OAR, OSHA, DPSST, OSHA, etc. Ensures SCHS policies and procedures are accurate, current, and consistent across the system.
Works collaboratively with Business Intelligence, IT, hospital and clinic leadership, and medical staff leadership to ensure performance data is analyzed, communicated, and routinely provided in accordance with achieving System Quality Key Performance Indicators (KPI's).
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.
Actively 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.
Engages, 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 team's delivery of customer service in a manner that promotes goodwill, is timely, efficient, and accurate.
Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies, and procedures, supporting the health system's corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violations of applicable rules, and cooperating fully with all company investigations and proceedings.
Supports the vision, mission, and values of the organization in all respects.
Supports Lean principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.
May perform additional duties of similar complexity within SCHS as required or assigned.
EDUCATION:
Required:
Master's 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 completed within one year of hire.
EXPERIENCE:
Required:
Minimum of seven (7) years of quality improvement experience in a healthcare setting. Three (3) years' experience in a management role within healthcare operations to include experience in a hospital or medical center dealing with regulatory, patient safety and/or clinical risk issues. Demonstrated knowledge of governmental and other regulatory standards and guidelines related to healthcare quality improvement. Examples include Joint Commission, AHRQ, CMS, IHI, and NQF.
Preferred : N/A
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:
Eligible for an in-state or out-of-state relocation bonus.
ST. CHARLES HEALTH SYSTEM
JOB DESCRIPTION
TITLE:
Director of Quality Management
REPORTS TO POSITION:
Chief Nurse Executive/Chief Clinical Officer
DEPARTMENT:
Quality Management
DATE LAST REVIEWED:
October 2025
OUR VISION:
Creating America's 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 St. Charles Health System quality and safety programs to achieve the following: 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 also 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 is critical in the support of clinical care and support functions to enhance the 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 the 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 (KPI's) and advance the vision for clinical excellence and the effective use of resources through continuous quality improvement.
In collaboration with executive leadership, set goals and strategic direction for units within the QM department and oversees work product 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 Key Performance Indicators (KPI's) goals and objectives. Assist and collaborate with local leadership at each site to create written quality assurance improvement plan (QAPI) on a yearly basis. In addition, contribute to ongoing monitoring of the plan and progress towards 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.
Responsible for oversight and collaboration of Infection Prevention and Control Plan; maintain annual risk assessment and program plan, oversee Safety Audits and required regulatory audits for all levels of care.
Prepares quality management reports for leadership, with key performance indicators with 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, the Legal & Risk on issues impacting quality management and process improvement opportunities and initiatives.
In coordination with the Legal and Compliance Departments, as applicable, serves as liaison to external regulatory agencies for purposes of patient and physician reporting, event investigation and response, including Oregon Health Authority,
Supports the hospital executive teams and others, 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 the various programs and processes, preparing the organization for reporting, surveys, and inspections, and by developing assessments, audits, and action plan responses. Includes TJC, CMS, CLIA, OAR, OSHA, DPSST, OSHA, etc. Ensures SCHS policies and procedures are accurate, current, and consistent across the system.
Works collaboratively with Business Intelligence, IT, hospital and clinic leadership, and medical staff leadership to ensure performance data is analyzed, communicated, and routinely provided in accordance with achieving System Quality Key Performance Indicators (KPI's).
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.
Actively 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.
Engages, 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 team's delivery of customer service in a manner that promotes goodwill, is timely, efficient, and accurate.
Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies, and procedures, supporting the health system's corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violations of applicable rules, and cooperating fully with all company investigations and proceedings.
Supports the vision, mission, and values of the organization in all respects.
Supports Lean principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.
May perform additional duties of similar complexity within SCHS as required or assigned.
EDUCATION:
Required:
Master's 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 completed within one year of hire.
EXPERIENCE:
Required:
Minimum of seven (7) years of quality improvement experience in a healthcare setting. Three (3) years' experience in a management role within healthcare operations to include experience in a hospital or medical center dealing with regulatory, patient safety and/or clinical risk issues. Demonstrated knowledge of governmental and other regulatory standards and guidelines related to healthcare quality improvement. Examples include Joint Commission, AHRQ, CMS, IHI, and NQF.
Preferred : N/A
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: