Job Description

Bend, OR

DEPARTMENTAL SUMMARY: The Quality Management Department provides essential services to St Charles Health System (SCHS) including:  Quality Improvement support, Accreditation and licensing expertise, Auditing support, Data Abstraction, Data Analysis, Document Library management and support, and Patient Experience data and program management, and Ongoing Professional Practice Evaluation.


POSITION OVERVIEW:  The Director of Quality Management at St. Charles Health System provides oversight and direction to the St. Charles Health System’s quality department and programs to achieve the following: performance improvement, quality assessments, accreditation status, patient satisfaction, regulatory compliance and licensing.  This role is critical in the support of clinical care and support functions to enhance the safety and experience for patients, families, and caregivers. This position manages Caregivers in the Quality Department.



Partners with the campus executive leadership teams and departments to ensure that the quality program effectively measures, assesses and continuously improves the care and services provided.


Serves as a key partner for Medical Staff and administrative leaders to achieve True North goals and advance the vision for clinical excellence and the effective use of resources through continuous quality improvement.


Sets strategic direction for units within the QM department and oversees work product for: Regulatory Affairs, Patient Experience, Quality Data, Quality Improvement, Clinical Documentation Integrity, and others as assigned.


Develops, implements, and monitors the QM annual plan and budgets toward the achieving True North goals and objectives.


Manages the organization’s accreditation, regulation, and licensing activities by communicating the various programs and processes, preparing the organization for reporting, surveys, and inspections, and by developing assessments, audits, and action plan responses. Includes TJC, CMS, CLIA, OAR, OSHA, etc. 


Oversees the corporate Document Management System (DMS) in accordance with legal and regulatory requirements.  Ensures SCHS policies and procedures are accurate, current, and consistent across the system.


Works collaboratively with Safety, IT, hospital and clinic leadership and medical staff leadership to ensure performance data is analyzed, communicated and routinely provided in accordance with achieving True North.


Engages and supports leadership in developing process improvements based on best practice, standards, and regulations, in partnership with Value Improvement Practice and clinical/support operations. 


Actively participates in regional and state wide quality improvement/patient safety initiatives and represents SCHS interests (eg. Central Oregon’s CCO, PacificSource, OAHHS, NW Patient Safety Collaborative).


Supports and participates in activities that promote professional growth and development across the QM department.


Communicates (both written and orally) effectively and maintains professional relationships with caregivers, medical staff, patients, and guests.


Hires, directs, coaches and monitors the performance of all direct reports, to develop and maintain a high performance team that meets organizational and department goals.


Monitors and ensure all direct reports are current with compliance and safety requirements.  Implements and manages all organizational safety directives and goals.


Provides and oversees team’s delivery of customer service in a manner that promotes goodwill, is timely, efficient and accurate.


Conducts all activities with the highest standards of professionalism and confidentiality.  Complies with all applicable laws, regulations, policies and procedures, supporting the health system’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violations of applicable rules, and cooperating fully with all company investigations and proceedings.


May perform additional duties of similar complexity within SCHS as required or assigned.


Supports the vision, mission and values of the organization in all respects.


Supports Value Improvement Practice (VIP- Lean) principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.



Required: Bachelor's degree in healthcare administration, public health administration or related field required.          

Preferred: Master’s degree in healthcare administration, public health administration, nursing or related field.



Required: Lean leader training. Valid Oregon driver's license and ability to meet SCHS driving requirements.  Ability to travel to business functions/trainings/meetings and all SCHS worksites required

Preferred: Certified Professional in Healthcare Quality (CPHQ)



Required: Minimum of three years’ experience leading quality improvement in a healthcare setting. Demonstrated knowledge of governmental and other regulatory standards and guidelines related to healthcare quality improvement.  Examples include: Joint Commission, AHRQ, CMS, IHI, and NQF. 

Preferred: N/A 

Application Instructions

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