**POSITION SUMMARY** Responsible for the overall strategic direction and leadership of assigned departments including administrative, financial, compliance, quality improvement, technical, and personnel activities in accordance with established policies and standards. **ESSENTIAL FUNCTIONS AND RESPONSIBILITIES** + Provides oversight in the development and implementation of quality improvement and organizational excellence plans, related to quality functions. + Directs and coordinates the department's activities, and staff to ensure they are efficient, timely, and meet cost and quality objectives; and that all activities and services are carried out in compliance with local, state, federal, and governmental regulations, and laws. + Directs and leads process improvement projects and teams that achieve measurable, sustainable change, promoting service, process, and operational excellence. + Develops strong relationships with internal colleagues, external providers, and the medical community to provide high quality, responsive services. + Develops and trains personnel within the department and reviews and appraises their performance. Responsible for assuring competency of all staff. + Develops annual budget for areas of responsibility and works with department leaders and staff to implement the budget. Assures measures for staying within budgetary parameters. + Develops and implements business plans, evaluates existing programs using established productivity standards and metrics. Continuously improves operations to manage costs, improve efficiencies, quality, and service. + Acts as a resource and provides ongoing education for department staff and the organization regarding national and regional trends; adjusts quality improvement model to meet financial, regulatory, and clinical goals for the hospital in collaboration with the Executives. + Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies. + Performs other related duties as required and directed. #LI-KH1 **QUALIFICATIONS REQUIRED** + Bachelor’s degree in nursing, healthcare administration, business administration, engineering, or related field from an accredited educational institution. + Certification in Quality Improvement/ Patient Safety are of focus (i.e., CPHQ, ASQ, CQIA, Team STEPPS Master Trainer, Project Management) or must be obtained within two years of employment. + Five years of progressively responsible quality management in healthcare related experience that demonstrates a high level of understanding of the required knowledge, skills, and abilities and frequent involvement with senior management and physicians. + Two years of Regulatory and Accreditation experience such as CMS, Joint Commission, Healthcare Facilities Accreditation Programs, DNV. **QUALIFICATIONS PREFERRED** + Master's degree in nursing, healthcare administration, business administration, engineering, or related field from an accredited educational institution. + LEAN/Six Sigma Certification.