Director, Quality Management & Infection Prevention
POSITION SUMMARY: Provides strategic and operational leadership for Quality Management, Patient Safety, Performance Improvement, Accreditation, Regulatory Readiness, and Infection Prevention programs across UNC Health Southeastern and affiliated entities. Oversees organizational efforts to improve clinical outcomes, reduce patient harm, ensure regulatory compliance, prevent healthcare-associated infections, and foster a culture of safety and continuous improvement. Provides coordination and guidance for organization-wide performance improvement activities through direct leadership and data-driven decision-making. Oversees The Joint Commission, CMS, NHSN, and other regulatory and accrediting activities while ensuring continuous survey readiness. Directs infection prevention surveillance, outbreak management, and healthcare-associated infection reduction initiatives. Collaborates closely with physicians, nursing leaders, department directors, and executive leadership to achieve organizational quality, patient safety, and infection prevention goals.
EDUCATION, CREDENTIALS, TRAINING and EXPERIENCE:
Minimum Required:
- Bachelor's degree in Nursing, Public Health, Healthcare Administration, Clinical Science, or related healthcare discipline.
- Three (3) years of progressive leadership experience in healthcare quality, patient safety, performance improvement, accreditation, infection prevention, or regulatory compliance.
- Demonstrated experience with CMS, The Joint Commission, regulatory compliance, performance improvement methodologies, and healthcare data analysis.
Preferred:
- Master's degree in Nursing, Healthcare Administration, Public Health, Business Administration, or related field.
- Certified Professional in Healthcare Quality (CPHQ).
- Certification in Infection Prevention and Control (CIC).
- Lean, Six Sigma, or equivalent performance improvement certification.
ADDITIONAL SPECIALIZED KNOWLEDGE/SKILLS:
- Extensive knowledge of healthcare quality management, patient safety, accreditation, and regulatory compliance requirements.
- Thorough knowledge of CMS Conditions of Participation, The Joint Commission standards, CDC guidance, and NHSN reporting requirements.
- Strong analytical and data interpretation skills, including ability to evaluate trends, benchmarks, and outcomes data.
- Knowledge of infection prevention principles, epidemiology, surveillance methodologies, outbreak investigation, and healthcare-associated infection prevention strategies.
- Ability to lead multidisciplinary teams, facilitate change, and guide complex performance improvement work.
- Excellent oral, written, presentation, interpersonal, and human relations skills.
- Strong organizational, project management, critical thinking, and prioritization abilities.
- Expertise in performance improvement methodologies, patient safety practices, and data-driven decision-
- making.
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