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Director Quality Mgt

Job ID R1012423 Type Employee - Full Time Location Mount Holly, New Jersey Standard Hours 40

Establishes and facilitates the implementation of the Virtua Quality Plan and Continued Readiness Plan at their local facility and any associated licensed services. Drives the action plans to achieve STAR G&O targets for Quality and Patient Safety.  Assures compliance and continued readiness with all regulatory agencies in collaboration with department leadership. Manages the local resources for the collection of data, including but not limited to, for Core Measures, The Joint Commission, NJ Department of Health, and ensure accurate chart documentation that serves as the foundation for quality and pay for performance initiatives. Adept at working in a matrixed management reporting environment.

Position Responsibilities:

Local Senior Leader;

  • Member of Operations Management Group and takes Administrator on Call responsibilities
  • Collaborating with the VP of Quality, Safety and PI provides facility wide accountability for all system wide performance improvement and quality initiatives
  • Provides management of safety issues during off shift when immediate in nature and reports incident to the Risk Safety Manager for follow up investigation
  • As a senior leader with oversight of Patient Relations, managers and staff, assists in the development and drives action plans for the improvement of the overall patient experience 

Quality and Performance Improvement

  • Accountable for analysis of  STAR G&Os, quality data and leads local clinical, physician, ancillary and operations leaders and staff in the development and implementation of strategies to achieve required results.
  • Leads the local facility in continued readiness for The Joint Commission and NJ Dept. of Health accreditation and licensing surveys and other regulatory agencies.
  • Local expert with current knowledge in regulatory standards and NJ licensing standards. 
  • Drives compliance with regulatory standards and Conditions of Participation.
  • Leads rounds and tracers in support of continued readiness.
  • Works collaboratively and in support of system efforts in quality and accreditation.
  • Serves as the Chair of the local Quality Council, and other local interdisciplinary committees as appropriate to coordinate and implement quality initiatives based on outcomes.
  • Mentors unit and department directors in quality goals, analysis of their dashboards and the development of unit based action plans, which contribute positively to facility results.
  • Acts as a local expert in the performance improvement processes, educating and mentoring staff, managers and physicians in its use.
  • Is a local expert and role model in skills needed for leading and facilitating teams.
  • Is an active member on various system councils and system committees to provide input on the development and implementation of new initiatives and processes (including facilitation of FMEA’s.)
  • Provides HRO Education and supports HRO efforts
  • • Under the direction of the AVP of Accreditation leads local Joint Commission annual Periodic Performance Review by auditing, collecting data, organizing teams and assessing processes

    •Responds to patient complaints as requested.

Position Qualifications Required / Experience Required:

Requires five years of healthcare experience.

Experience in acute care facility and a broad base of knowledge in nursing practice, evidenced based care and management.

Required Education:

Bachelor’s Degree in a health related field.

Master’s degree preferred.


RN licensure. Certification in Health Care Quality preferred or willing to sit for CPHQ within 3 years

Certification in Health Care Quality required or eligibility to sit for CPHQ Exam.

  • Mission:

    Virtua helps you be well, get well, and stay well.

  • Vision:

    The trusted choice for personalized health care and wellness.

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