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Director of Quality

Benefits Eligibility (Employment Type):  Full-time benefits (32-40 hours per week)
Shift Type:  Variable
Shift Length:  8 Hours
Primary Location (City):  Springfield
State:  OR

PeaceHealth is seeking a Director of Quality for a 1.0 full time equivalent Exempt position. This position will be working Variable shift with shift durations of 8 Hours.

Req ID: 169827


Directs, controls and is accountable for Quality within their assigned facility or community; including PHMG.  Develop long and short-term business strategies, operational plans and oversees implementation.  Manage the design, structure, development and planning issues within scope of direction.  Responsible for quality, service and regulatory compliance for areas of responsibility. Demonstrate the Mission, Vision, and Values in the achievement of excellent clinical quality outcomes and   improved results in the Triple Aim (improved individual quality, improved population health, and lower costs of care); In partnership with the facility CMO and System Quality VP, lead the Community quality agenda to reach top decile performance and outcomes ensuring community alignment with system goals. Coordinate and facilitate quality improvement teams with a focus on quality, safety, compliance and risk mitigation.  Responsible for Patient Safety and Regulatory requirements in local community, partners with PeaceHealth patient safety and regulatory staff to achieve.  

1. In partnership with System Quality Vice President, leads the community inpatient and outpatient quality improvement initiatives to insure high clinical outcomes, improved patient safety, regulatory compliance and enhanced patient experience.   Lead clinical quality improvement in collaboration with the Chief Medical Officer, Community Quality Committees, Medical Staff leaders, Clinical Operations, and frontline staff.     

2. Serves as chair for Quality Management Committee and supports other quality committees provide consultation to clinical quality improvement teams.  Responsible to allocate Network/Community quality, safety and process improvement resources to achieve goals.  

3. Leads implementation of PeaceHealth Quality Plan Supports System CNO & CMO and community senior leaders, in preparing ongoing performance reports to the Community Quality Committee(s) and Board.    

4. Leads and supports managers, physician leaders, departments and staff to transform healthcare delivery to ensure patient engagement in providing care that is safe, efficient, effective, timely, and equitable.  Leads clinical teams to achieve highest quality outcomes.
5. Coordinates organizational strategies to enhance the alignment and implementation for optimum performance and patient outcomes; with a focus on the continuum of care delivery services.  
6. Manages flow of patient information, including the collection and reporting of clinical indicators and measures and adoption of clinical decision support functions.   

7. Actively support system approaches to clinical quality adopting system standards, shared learnings and implementing best practices.   
8. Manages accreditation surveys, partners with regulatory consultant to assure readiness for survey, monitoring of required metrics, corrective and preventive action planning as appropriate and follow-up after survey. Leads internal auditing at facility and subsequent action plans. In consultation with the Regulatory and Accreditation team, provides leadership to ensure compliance with regulatory, accreditation and licensure requirements
9. Works with the CMOs and the Patient Safety Coordinators in conducting a review of patient incidents, analysis, approvals of action plans and follow up monitoring. Uses best practice standards within health care environments; guides development of clinical risk reduction initiatives and methodologies. 

10. Partners with Process Improvement team to assure lean approach, with standard improvement methodologies and tools.  Facilitation of root cause analysis, Failure Mode and Effects Analysis and occurrence reporting management. 

11. Partners with medical staff leaders to align performance indicators to support peer review, physician performance expectations, and outcomes studies.   

12. Performs other duties as required.


EDUCATION:    Bachelor’s degree required in Nursing, Business or a healthcare related field. Master’s degree required or a combination of education and professional experience that provides the incumbent with the requisite knowledge, skills and ability to successfully perform the job with the agreement to obtain within 3 years of date of hire. If a Nurse:  BSN or MSN required upon hire.


    Minimum of 7 years in clinical quality improvement.
    Minimum of 5 years of management experience required.


    Certified Professional in Healthcare Quality (CPHQ) is required within two and a half years of hire.
    Maintain certification/licensure in clinical field.  



    Ability to deliver financial results for areas of accountability.
    Must be able to lead successfully in a matrix organization. 
    Must demonstrate passion for continuous improvement; including skills in QI methodologies and tools.    
    Must have the ability to communicate to multiple audiences, prioritize and maintain perspective for organization’s vision and quality. 
    Must have a strong understanding of tenants of ISO 9000.1 and knowledge of regulatory/accreditation and licensure standards
    Must be able to work effectively with multiple individuals/groups both internally and externally.  Must be able to challenge effectively at all levels and teams. 
    Demonstrates strong planning skill, and execute from a strategic level to a meeting level. 
    Must be able to manage staff.
    Displays optimistic, relationship and trust-oriented, forward looking and flexible approach.
    Knowledge of disease management/care management and utilization management








Please apply online to be considered. For full consideration of your skills and abilities, please attach a current resume with your application.


About PeaceHealth


PeaceHealth, based in Vancouver, Wash., is a not-for-profit Catholic health system offering care to communities in Washington, Oregon, and Alaska. PeaceHealth has approximately 16,000 caregivers, a multi-specialty medical group practice with more than 900 providers and 10 medical centers serving both urban and rural communities throughout the Northwest. In 1890, the Sisters of St. Joseph of Peace founded what has become PeaceHealth. Today, PeaceHealth is the legacy of its founding Sisters and continues with a spirit of respect, stewardship, collaboration and social justice in fulfilling its Mission. 


We offer competitive compensation, a robust benefits package and a collaborative, Mission-driven work environment! To learn more about working at PeaceHealth and the Springfield community please visit our homepage:


Get a feeling for the Spirit of PeaceHealth through this three-minute video, and visit us on Facebook or LinkedIn!


Questions? Review our Employment FAQ or email Please note this email does not accept resumes or applications.


Location: Springfield, SHMC at Riverbend (420)
Job Category:  Leadership 
Shift:  Variable
Shift Length: 8 Hours
FTE: 1.0
Work Type:  Full Time
Hourly compensation starts at: $52.05, more depending on experience
Required Certifications/Licensure: 


PeaceHealth is committed to providing equal employment opportunities to all qualified job applicants and employees without regard to the following statuses: protected veteran; qualified individual with a disability; race; ethnicity; religion; gender; pregnancy; gender identity; national origin; age; genetic information; sexual orientation; or any other protected status in accordance with local, state, or federal laws.


The above information is intended to indicate the general nature and level of work performed by this position. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of caregivers assigned to this job.


Posting Notes: Springfield || Leadership || Business, Administrative, & Facilities Leadership || Full Time || QUALITY IMPROVEMENT




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