Overview

Director of Quality and Risk Management 

Reports To: Chief Executive Officer (CEO)

 

Position Summary:

 

The Director of Quality and Risk Management provides strategic leadership and operational oversight for the hospital’s quality improvement, patient safety, and risk management programs. This role ensures compliance with federal, state, and accrediting body requirements while supporting a culture of safety, accountability, and continuous performance improvement within the inpatient psychiatric setting. The Director partners with executive leadership and department leaders to proactively identify risk, improve outcomes, and sustain regulatory readiness.

 

Essential Duties and Responsibilities:

 

Quality Management & Performance Improvement

• Lead the hospital’s Quality Assessment and Performance Improvement (QAPI) program in accordance with CMS Conditions of Participation and accreditation standards.
• Develop, monitor, and report quality metrics relevant to inpatient psychiatric care.
• Analyze quality and risk data to identify trends and opportunities for improvement.
• Facilitate performance improvement projects, including root cause analyses and action plans.
• Prepare quality reports for executive leadership, medical staff, and the Governing Body.

Risk Management & Patient Safety

• Direct the hospital’s risk management program, including incident reporting, investigation, tracking, and follow-up.
• Oversee review and response to adverse events, near misses, and sentinel events.
• Coordinate Root Cause Analyses (RCA) and Failure Mode and Effects Analyses (FMEA).
• Monitor behavioral health–specific risks such as suicide/self-harm, elopement, aggression, restraint and seclusion, and environmental safety.
• Partner with leadership to implement risk reduction strategies and corrective action plans.

Regulatory & Accreditation Compliance

• Ensure compliance with CMS Conditions of Participation, state licensing requirements, and accreditation standards.
• Serve as the primary point of contact for regulatory surveys and inspections.
• Coordinate survey preparation, on-site support, and post-survey corrective actions.
• Maintain policies, procedures, and documentation related to quality and risk.
• Track regulatory changes and communicate impacts to leadership.

Education, Communication & Culture of Safety

• Promote a culture of safety, transparency, and continuous improvement.
• Support staff education related to quality and patient safety.
• Encourage incident and near-miss reporting using just culture principles.
• Provide consultation to department leaders on quality and risk concerns.

Leadership & Collaboration

• Collaborate with the CEO and department leaders to align quality initiatives with organizational goals.
• Participate in leadership and quality committees.
• Provide oversight to quality and risk staff, if applicable.

Requirements/Qualifications

Qualifications:

 

Education

• Bachelor’s degree in Healthcare Administration, Business Administration, Public Health, or related field required.
• Master’s degree preferred.

Experience

• Two (2) years of progressive experience in healthcare quality improvement, risk management, compliance, or performance improvement preferred.
• Behavioral health or inpatient psychiatric experience preferred but not required.

Knowledge, Skills, and Abilities

• Knowledge of healthcare quality and risk management principles.
• Strong analytical, organizational, and problem-solving skills.
• Effective written and verbal communication skills.
• Ability to collaborate with multidisciplinary teams and executive leadership.
• Professional judgment and discretion.

Physical and Work Requirements

• Ability to work in an inpatient psychiatric hospital environment.
• Ability to sit, stand, walk, and move throughout the facility.
• Flexibility to work additional hours during surveys or investigations.

Hospital/Program Description

The Permian Basin Behavioral Health Center is a mental health facility located between Midland and Odessa. The Center will provide inpatient and outpatient mental health services to help individuals of all ages overcome their challenges. This exciting partnership between Midland County Hospital District and Ector County Hospital District marks the start of a new cha