Director, Quality Management

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 Depar