Job Summary:
The System Director of Quality, Infection Prevention, and Employee Health is a dynamic leader responsible for advancing patient safety, regulatory compliance, and workforce well-being. This role requires strong leadership and management skills, including effective communication, strategic thinking, and collaboration across departments. The Director fosters a culture of continuous improvement, ensuring high standards in clinical quality, infection control, and employee health practices.
The position will oversee the development and implementation of quality initiatives, infection prevention protocols, and employee health programs, ensuring alignment with hospital goals and regulatory requirements across the health system. The Director will promote a positive and proactive environment focused on patient outcomes, staff engagement, and physician satisfaction. This role involves direct interaction with hospital administration, clinical teams, regulatory agencies, and the public.
The ideal candidate is a critical thinker, innovative, team-oriented, self-motivated, and accountable, with a commitment to excellence in healthcare delivery and employee wellness.
Qualified Candidate:
Educational and Certification Requirements
- Graduate of an accredited school of Nursing, minimum of an Associate Degree of Nursing (ADN) required; Bachelor of Science in Nursing (BSN) or Master’s in healthcare-related field preferred.
- Experience: At least 3-5 years of experience in nursing, with increasing responsibility in leadership roles.
- Skills: Strong leadership, communication, and organizational skills; ability to handle high-stress situations effectively.
- Must have and maintain certifications as follows: BLS, ACLS, PALS or ENPC, and TNCC. Certification in Infection Control (CIC), Certified Professional in Healthcare Quality (CPHQ), or Occupational Health Nursing (COHN/COHN-S) is highly desirable.
Essential Skills:
- Principles of organization
- Problem Solving & Collaboration
- Strong oral and written communication skills
- Ability to implement evidence-based practice guidelines
- Human Resources management
- Strategies of nursing management
- Familiar with software technologies
- Foundations of healthcare facility laws
Reports to: Director of Nurses (DON)/Chief Nursing Officer (CNO)
Positions Supervised: Infection Preventionist(s), Quality Analyst, and Employee Health Nurse(s)
Responsibilities:
· Quality & Performance Improvement:
o Lead system-wide hospital initiatives to improve patient safety and clinical outcomes.
o Monitor and analyze performance metrics, quality indicators, and patient satisfaction data.
o Facilitate quality committees and support departments/facilities in achieving performance goals.
· Employee Health & Wellness:
o Oversee system-wide employee health services, including pre-employment, annual screenings, immunizations, and workplace safety initiatives.
o Ensure compliance with OSHA standards and hospital employee health policies.
o Develop wellness programs that promote employee well-being and reduce occupational risk.
· Infection Prevention & Control:
o Develop, implement, and evaluate infection prevention policies and procedures.
o Monitor hospital-acquired infections (HAIs) and report data as required to state and federal agencies.
o Lead system-wide hospital preparedness for outbreaks, pandemics, and infection-related emergencies.
o Provide education to staff on infection prevention practices and compliance.
· Compliance & Regulatory Readiness:
o Ensure system-wide hospital compliance with federal, state, and accrediting body standards related to quality, employee health, and infection prevention.
o Lead survey readiness activities and coordinate corrective action plans as needed.
o Maintain records and documentation for internal and external audits.
· Financial & Resource Management:
o Develop and manage department budgets for quality, employee health, and infection prevention.
o Optimize use of resources while ensuring effective operations and compliance.
o Evaluate cost-effectiveness of initiatives to ensure sustainability.
Structured Pillars:
1. Leadership & Management Percent of time: 25%
- Oversight: Provide vision, direction, and oversight for quality, employee health, and infection prevention programs. Mentor and support departmental staff.
- Policy Implementation: Develop and enforce policies and procedures to maintain high standards of care.
- Strategic Planning: Create and implement plans to improve department efficiency.
2. Quality & Patient Safety Percent of time: 25%
- Patient Safety: Drive continuous improvement in patient outcomes, safety, and satisfaction.
- Quality Improvement: Monitor and improve hospital quality metrics.
- Employee Health & Infection Prevention: Ensure staff health programs and infection control practices meet all regulatory requirements. Lead investigations of employee exposures and infection outbreaks.
3. Operational Efficiency Percent of time: 20%
- Daily Operations: Streamline processes for quality reporting, employee health services, and infection surveillance.
- Resource Management: Optimize the use of resources and optimize workflows.
- Performance Metrics: Track and analyze key performance indicators (KPIs) to identify areas for improvement.
4. Financial Management Percent of time: 15%
- Budgeting: Develop and manage the department's budget, ensuring cost-effective operations.
- Financial Reporting: Monitor financial performance and report on budget adherence and financial health.
- Cost Control: Identify and implement strategies to reduce costs without compromising care quality.
5. Compliance & Safety Percent of time: 15%
- Regulatory Compliance: Ensure the department adheres to all relevant laws, regulations, and healthcare standards. Maintain readiness for inspections and surveys.
- Safety Protocols: Implement and monitor safety protocols to protect patients and staff.
- Incident Management: Handle and investigate incidents, ensuring corrective actions are taken to prevent recurrence.
Job Type: Full-time
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Employee discount
- Health insurance
- Life insurance
- Paid time off
- Vision insurance
Work Location: In person
