JOB SUMMARY: The Quality Director/HIPAA & Compliance Officer is a combined leadership role responsible for overseeing hospital-wide quality improvement initiatives, regulatory compliance, risk management, patient safety, and ensuring adherence to both healthcare regulations and internal standards. This position integrates responsibilities for improving patient care quality, managing risk, ensuring HIPAA compliance, infection prevention, employee health requirements and leading performance improvement initiatives across the hospital. The role requires a strategic thinker who can effectively balance patient care objectives with regulatory and safety requirements, while fostering a culture of continuous improvement. Position reports to Chief Nursing Officer. Exempt. Key Responsibilities: Compliance Management: * Ensure the hospital complies with all relevant federal, state, and local healthcare regulations, including HIPAA (Health Insurance Portability and Accountability Act), CMS (Centers for Medicare & Medicaid Services), The Joint Commission standards, and other regulatory bodies. * Oversee and ensure effective implementation of compliance programs aimed at protecting patient privacy, reducing fraud and abuse, and adhering to healthcare laws. * Conduct regular audits and assessments to identify compliance gaps and implement corrective actions to address violations. * Serve as the primary point of contact for compliance-related matters, including HIPAA breaches, audits, and investigations. * Act as the primary liaison with regulatory agencies, ensuring timely responses to inquiries, inspections, and investigations. * Quality Improvement & Performance Management: * Design and implement organization-wide performance improvement (PI) strategies, utilizing data to monitor hospital performance and identify areas for improvement including performance of "Root Cause Analysis" on certain high-risk situations and occurrences. * Oversee the collection, analysis, and reporting of data related to quality metrics, patient safety, and clinical outcomes to senior leadership and key stakeholders. * Ensure that quality improvement projects align with evidence-based practices and meet national standards of care. * Promote a culture of continuous improvement, training and mentoring staff on best practices in quality and safety management. * Oversee Infection Prevention processes and performance improvement. * Ensure that Employee Health requirements are met according to federal and local regulations. * Organize and facilitate workshops, Kaizen events, and training sessions to empower staff and leaders in performance improvement efforts. * Develop strategies to streamline workflows, reduce waste, and enhance patient and staff satisfaction. * Mentor and coach staff in Lean/Six Sigma principles, supporting certifications and competency development. * Risk Management & Patient/Employee Safety: * Develop and execute risk management strategies to identify, evaluate, and mitigate risks to patient safety, hospital operations, and financial performance. * Lead hospital efforts to prevent adverse events, including medical errors, patient falls, infections, and other safety risks, through proactive risk assessments and process improvements. * Investigate incidents, near misses, patient concerns, grievances , and safety events to identify root causes and recommend corrective actions. * Collaborate with medical staff, department heads, and leadership teams to develop risk reduction strategies and monitor their effectiveness. * Ensure that the hospital maintains a comprehensive incident reporting system and promotes a culture of transparency and accountability. * HIPAA Compliance & Privacy Protection: * Act as the HIPAA Officer, ensuring the hospital complies with all aspects of HIPAA regulations, safeguarding patient privacy, and confidentiality. * Implement and oversee privacy and security protocols to protect sensitive patient information across all hospital systems. * Conduct regular HIPAA training for hospital staff to raise awareness of privacy policies, patient rights, and the importance of safeguarding personal health information. * Investigate potential HIPAA violations, breaches, and data security incidents, leading efforts to mitigate risks and ensure corrective actions are taken. * Coordinate with IT and security teams to ensure compliance with cybersecurity protocols to protect electronic health records (EHR) and other patient data. * Accreditation & Regulatory Oversight: * Lead the hospital's efforts to achieve and maintain accreditation from relevant regulatory and accreditation bodies such as The Joint Commission, federal and state-level health agencies. * Ensure that the hospital adheres to accreditation standards by conducting periodic self-assessments, audits, and preparing for surveys. * Prepare documentation, reports, and presentations for regulatory agencies and auditors as required. * Staff Education, Training, and Support: * Develop and implement training programs on compliance, quality improvement, patient safety, HIPAA regulations, and risk management to ensure all staff understand their responsibilities. * Provide leadership and support for clinical and administrative teams in implementing best practices for quality improvement, risk management, and compliance. * Promote a culture of quality, safety, and compliance through continuous education, staff engagement, and communication. * Collaboration and Communication: * Serve as a liaison between the hospital leadership, medical staff, and regulatory agencies on matters related to compliance, quality, and risk management. * Communicate effectively with staff at all levels to ensure understanding and commitment to hospital policies and procedures related to compliance and quality improvement. * Work closely with department heads to develop and refine quality metrics, reporting tools, and risk management strategies. * Financial Oversight & Resource Management: * Oversee the budgeting and financial planning for compliance, quality improvement, and risk management initiatives. * Ensure efficient use of resources while maintaining a focus on meeting regulatory and accreditation standards. Qualifications: * Education: * High school diploma or equivalent required. Bachelor's Degree preferred. * Certification: * Certification (RIMS-CRMP or CPHRM) required within 1 year of hire. * Lean/Six Sigma certification (Yellow Belt, Green Belt, or Black Belt) preferred. * Experience: * Minimum of 5 years management experience in hospital setting required. * Previous experience in performance improvement, compliance, and risk preferred. * Skills and abilities: * Strong knowledge of healthcare regulations, quality standards, risk management frameworks, and HIPAA requirements. * Excellent organizational, analytical, and problem-solving skills. * Ability to communicate complex regulatory issues clearly to all levels of staff. * Strong leadership, collaboration, and interpersonal skills. * Proficiency in compliance and risk management software, audit tools, and Microsoft Office Suite. * Expertise in change management and organizational development. * Familiarity with tools such as RCA (Root Cause Analysis), FMEA (Failure Mode and Effects Analysis), and PDCA (Plan-Do-Check-Act). FUNCTIONAL DEMANDS Functional Job Requirements: Job requirements include, but are not limited to: sitting, standing, walking, kneeling, bending, squatting and reaching. Requires good finger dexterity, repetitive motions with hands and fingers. Requires ability to have good vision and hearing. Pushing and pulling equipment may be necessary. Lifting Requirements Job requires light lifting on an occasional basis. Reasonable Accommodations Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising the job duties.