Director Quality / Regulatory Readiness

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Leads associates and programs for quality management, infection prevention, and regulatory and accrediting agency reporting and continuous survey readiness across the acute and ambulatory care spectrum. 

  • Develops and maintains a process that engages Care Site leaders in the periodic assessment and prioritization of system-wide quality initiatives.
  • Supports quality improvement collaboratives that identify unwarranted variation in care and support the adoption of best practices to achieve and maintain exceptional outcomes.
  • Works with and supports needs of various Quality Committees such as the Ambulatory Quality Committees for regional quality needs and to provide alignment with the SCL Health Quality and Safety Committee; local Quality Performance Excellence Committees to create alignment in reporting with the SCL Health Quality and Safety Committee; the Pharmacy Director and the Pharmacy Quality Committee as needed; assists the System Chief Nursing Officer in developing a nursing quality committee and provide ongoing support.
  • Supervises the System Infection Prevention Manager in the development of an effective infection prevention program
  • Develops a data management system that effectively allows System and Care Site leaders to monitor, evaluate, and improve quality and safety.  Provide effective data tools, training, analytics, and reports that meet key customer requirements (System, Care Sites, regulatory agencies, etc.);
  • Develops and maintains a quality measures abstracting services for our care sites that meets regulatory/accrediting reporting requirements for required publicly-reported measures.  Develops and maintains an electronic clinical quality measurement (eCQM) process that meets regulatory/accrediting reporting requirements and can be expanded to meet new or changing reporting requirements.
  • Monitors, evaluates and improves performance on federal pay for performance and penalty programs (e.g., Value-Based Purchasing, Hospital-Acquired Conditions, Readmissions).  Works in collaboration with Payer Contracting & Strategy to assess, negotiate, and perform on commercial pay for performance contracts.
  • Ensures that care sites have the necessary resources, tools, training, processes and support to maintain continuous survey readiness.  Provides technical assistance and consultation as requested for rectifying any regulatory or accreditation concerns.


  • Bachelor degree in a clinical field
  • Master’s degree
  • Advanced training and expertise in healthcare quality, safety, and outcome improvement and reporting
  • Certified Professional in Healthcare Quality (CPHQ) or other related certification, preferred
  • Ten (10) years healthcare experience
  • Five (5) years in clinical quality
  • Experience supervising associates and working with health care data issues, regulatory readiness, change management and process improvement.
  • Project management, High Reliability Organizing, Lean or other process improvement methodology
  • Experience working at a System or Corporate level
Organization: Corporate, Various Locations
Primary Location: CO-Denver/Boulder/Surrounding Areas-Broomfield
Department: SYS-Quality Assurance
Schedule: Full-time
Shift: Day Shift
Job Posting: 9/21/2017 10:58:42 PM
FTE: 1
Job Number: 17007661
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