Job Description Summary
The Director, Quality Improvement provides strategic leadership, oversight, and operational direction for quality improvement, regulatory readiness, accreditation compliance, and performance improvement initiatives across the Shirley Ryan AbilityLab system of care, inclusive of the Alliances. This role partners closely with clinical, operational, and administrative leaders to foster a culture of continuous improvement, patient safety, accountability, and high reliability in alignment with organizational goals and Envision 2030 priorities.
The Director leads enterprise quality improvement initiatives, coordinates accreditation and regulatory readiness activities, advances data-informed decision-making, and supports ongoing compliance with applicable standards and requirements, including CARF, The Joint Commission, CMS, and other regulatory bodies. The Director serves as a key advisor and partner to clinical, operational, and administrative leaders to advance quality outcomes, patient safety, operational effectiveness, and organizational excellence.
Job Description
The Director, Quality Improvement will:
- Provide leadership and direction for quality improvement, performance improvement, accreditation, and regulatory readiness programs across the Shirley Ryan AbilityLab system of care, with initial focus at the flagship hospital
- Develop and lead quality and performance improvement initiatives utilizing evidence-based methodologies and frameworks to advance regulatory compliance, patient outcomes, and operational excellence across the Shirley Ryan AbilityLab system of care, with initial focus at the flagship hospital.
- Partner with leaders to align quality initiatives with strategic organizational priorities and Envision 2030 goals.
- Promote a culture of continuous improvement, transparency, accountability, and interdisciplinary collaboration.
- Oversee the identification, development, tracking, analysis, and reporting of key quality, patient safety, operational, and regulatory performance measures. Identify trends, risks, and opportunities for improvement.
- Collaborate with leaders and teams to identify opportunities for improvement and implement sustainable corrective action plans.
- Lead the annual development, evaluation, and update of the organization's Quality Assurance and Performance Improvement (QAPI) Plan and support ongoing monitoring of organizational performance against established priorities.
- Support departments in developing measurable goals, dashboards, and improvement plans to drive organizational performance.
- Direct organizational accreditation and regulatory readiness efforts, including preparation for CARF, The Joint Commission, CMS, and other applicable surveys and reviews.
- Maintain knowledge of evolving regulatory and accreditation standards and assess and communicate organizational impacts, risks, and recommended actions to leadership.
- Partner with operational and clinical leaders to ensure policies, procedures, workflows, and practices align with regulatory requirements and best practices.
- Oversee regulatory and accreditation survey response activities, corrective action plans, and ongoing monitoring to ensure timely and sustained compliance.
- Oversee the development and presentation of quality and performance reports, dashboards, and executive-level analyses to support organizational decision-making.
- Oversee the development and presentation of quality and performance reports, dashboards, and executive-level analyses that provide meaningful insights, support organizational accountability, and inform leadership decision-making.
- Serve as a subject matter expert and resource for quality improvement, accreditation, regulatory readiness, and performance improvement methodologies.
- Partner with leaders, physicians, clinicians, and operational teams to build organizational capability and accountability for quality, patient safety, and performance improvement.
- Develop and facilitate training, education, and communication strategies related to accreditation standards, regulatory requirements, and quality initiatives.
- Represent Quality and Safety on organizational committees, councils, and interdisciplinary teams as assigned.
- Perform all other duties that may be assigned in the best interest of the Shirley Ryan AbilityLab.
Reporting Relationships
- Reports directly to the Executive Director, Quality and Safety.
- Provides leadership and oversight to assigned quality, accreditation, regulatory, and performance improvement staff.
Knowledge, Skills & Abilities Required
- Master's degree in healthcare administration, business administration, public health, nursing, allied health or a related healthcare field required.
- Minimum of seven years of progressively responsible experience in healthcare quality improvement, accreditation, regulatory compliance, patient safety, or performance improvement, within a hospital, rehabilitation, or complex healthcare environment. .
- Relevant quality, patient safety, accreditation, or healthcare certification (e.g., CPHQ, CPPS) is required or obtained within two years of hire.
- Comprehensive knowledge of healthcare quality and performance improvement methodologies, accreditation standards, and regulatory requirements, with demonstrated experience leading accreditation and regulatory readiness activities. Knowledge of CARF, The Joint Commission, CMS, and other applicable healthcare regulatory and accreditation requirements.
- Strong analytical and problem-solving skills with demonstrated ability to interpret complex quality, patient safety, operational and regulatory data and translate findings into actionable recommendations.
- Exceptional communication, facilitation, and relationship-building skills, with demonstrated ability to collaborate with and influence physicians, clinical leaders, operational leaders, and other stakeholders across all levels of the organization.
- Demonstrated project and change management capabilities, including the ability to lead complex, cross-functional initiatives from planning thru implementation and sustained adoption.
Working Conditions
- Normal office environment with little or no exposure to dust or extreme temperature undefined
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification.They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified.
Pay and Benefits*:
Pay Range:
$116,700.00 - $193,800.00
Benefits:
Shirley Ryan AbilityLab offers a comprehensive benefits program that is competitive with our industry peers in our geographic locations: https://www.sralab.org/benefits
*Benefits and benefits eligibility can vary by position. Actual compensation will be determined by equity and qualifications of the role.
