Job SummaryThe Corporate Director of Quality Management System (QMS) provides strategic leadership, coordination, and oversight for the organization's Quality Management System across all regional hospitals, ambulatory settings, and affiliated entities. This position is responsible for ensuring standardization, deployment, integration, and continuous improvement of quality management principles, performance improvement methodologies, regulatory compliance processes, and policy governance throughout the health system.
Working collaboratively with executive leadership, clinical leaders, operational leaders, and facility quality teams, the Corporate Director develops and implements system-wide quality strategies that promote high reliability, patient safety, regulatory compliance, operational excellence, and achievement of organizational goals. The position serves as the primary enterprise resource for quality management systems, performance improvement methodologies, quality governance, and policy standardization across all regional facilities.
This role provides oversight of regional quality programs, quality committees, quality metrics, performance improvement activities, and the system-wide policy and procedure management process to ensure consistency, compliance, and alignment with organizational priorities.
Responsibilities•
Quality Management System Leadershipo Provide strategic leadership for the design, implementation, deployment, maintenance, and continual improvement of the Quality Management System (QMS).
o Collaborate with executive leadership to establish the vision, mission, structure, and strategic priorities of the QMS.
o Ensure alignment of quality initiatives across all hospitals, ambulatory sites, physician practices, and affiliated entities.
o Facilitate integration of quality, safety, regulatory, operational excellence, and performance improvement activities throughout the organization.
o Promote a culture of continuous improvement, accountability, transparency, and high reliability.
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Regional Quality Oversight o Provide direct oversight and coordination of regional quality management programs across all facilities and service lines.
o Establish and monitor system quality goals, performance indicators, dashboards, and outcome measures.
o Analyze organizational quality trends and identify opportunities for improvement.
o Ensure implementation of evidence-based quality improvement methodologies and best practices.
o Guide facility leadership in developing corrective action plans for identified performance gaps.
o Monitor progress toward strategic quality objectives and regulatory requirements.
o Participate in executive reviews of quality, safety, and operational performance.
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Regional Policy and Procedure Governance o Provide oversight for enterprise and regional policy and procedure development, review, approval, implementation, and maintenance processes.
o Chair or support system Policy and Procedure Committees and governance councils.
o Ensure policy standardization across facilities whenever operationally appropriate.
o Coordinate interdisciplinary review and approval processes for corporate policies.
o Establish controls to ensure timely review, revision, and retirement of policies.
o Monitor policy compliance through audits, performance reviews, and regulatory readiness activities.
o Ensure policies remain aligned with applicable regulatory, accreditation, legal, and operational requirements.
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Performance Improvement and Operational Excellence o Lead implementation of system-designated performance improvement methodologies.
o Serve as subject matter expert in Quality Improvement (QI), Performance Improvement (PI), Lean, Six Sigma, High Reliability, and change management principles.
o Facilitate enterprise improvement projects with measurable clinical, operational, financial, and patient experience outcomes.
o Promote standardization of improvement practices across facilities.
o Provide consultation and coaching to leaders and teams regarding improvement strategies and project execution.
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Regulatory and Accreditation Support o Ensure QMS processes support compliance with accreditation standards, state regulations, federal regulations, and organizational requirements.
o Collaborate with regulatory, compliance, infection prevention, risk management, and patient safety leaders to maintain survey readiness.
o Monitor quality system performance related to accreditation outcomes and corrective action plans.
o Assist facilities with preparation for regulatory and accreditation surveys.
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Governance and Committee Leadership o Support governance structures related to quality management and performance improvement.
o Coordinate agendas, reports, action plans, and documentation for quality-related governance committees.
o Facilitate communication among executive leadership, board committees, regional leadership, and operational teams.
o Prepare executive and board-level quality reports and presentations.
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Education and Organizational Development o Develop educational programs supporting quality management, performance improvement, and policy governance.
o Provide mentoring, coaching, and consultation to quality professionals and operational leaders.
o Promote competency development related to quality methodologies and regulatory requirements.
o Foster leadership development within quality management functions.
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Data Analysis and Reporting o Oversee development and dissemination of quality performance reports and dashboards.
o Utilize data analytics to identify trends, risks, and opportunities for improvement.
o Present quality system performance results to executive leadership, governing bodies, and operational teams.
o Support strategic decision-making through data-driven recommendations.
Knowledge, Skills & AbilitiesPatient Group Knowledge (Only applies to positions with direct patient contact)
The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment or care as defined by the department's identified patient ages. Specifically the employee must be able to demonstrate competency in: 1) ability to obtain and interpret information in terms of patient needs; 2) knowledge of growth and development; and 3) understanding of the range of treatment needed by the patients.
Competency Statement
Must demonstrate competency through an initial orientation and ongoing competency validation to independently perform tasks and additional duties as specified in the job description and the unit/department specific competency checklist.
Common Duties and Responsibilities
(Essential duties common to all positions)
1. Maintain and document all applicable required education.
2. Demonstrate positive customer service and co-worker relations.
3. Comply with the company's attendance policy.
4. Participate in the continuous, quality improvement activities of the department and institution.
5. Perform work in a cost effective manner.
6. Perform work in accordance with all departmental pay practices and scheduling policies, including but not limited to, overtime, various shift work, and on-call situations.
7. Perform work in alignment with the overall mission and strategic plan of the organization.
8. Follow organizational and departmental policies and procedures, as applicable.
9. Perform related duties as assigned.
Education • Master's Degree (Required) Education: Master's degree in Healthcare Administration, Nursing, Public Health, Business Administration, Quality Management, or related healthcare field.Experience: Minimum of eight (8) years of progressive healthcare quality, performance improvement, patient safety, regulatory, or operational leadership experience. Minimum of five (5) years of management experience in a complex healthcare system. Demonstrated experience leading enterprise-wide quality programs and multidisciplinary teams. Experience overseeing policy and procedure governance and standardization across multiple facilities.
Credentials • No Certification, Competency or License Required
Work Schedule: Days
Status: Full Time Regular 1.0
Location: Northgate-400 Association Dr.
Location of Job: US:WV:Charleston
Talent Acquisition Specialist: Anita J. Ferguson
[email protected] 
