Director of Quality, Safety, and Regulatory Programs

Provides organizational leadership and subject matter expertise in quality, safety, and regulatory affairs across all Shore Regional Health entities. Leads efforts to maintain continuous regulatory readiness and compliance with applicable accrediting and regulatory organizations. Collaborates with internal and system-wide partners to ensure alignment with UMMS quality, safety, and regulatory standards. Oversees quality reporting and data integrity to support performance improvement and patient safety. Identifies data-driven opportunities for improvement and partners with leaders to implement effective solutions.

Primary Responsibilities

• Develop, implement, and lead organization‑wide regulatory, quality, and patient safety programs to ensure continuous compliance with accreditation standards, Medicare and Medicaid Conditions of Participation and Coverage, and State of Maryland regulatory requirements.
• Serve as the primary organizational liaison to accrediting and regulatory agencies, managing official communication, survey readiness activities, corrective action plans, and regulatory inquiries to ensure timely and accurate responses.
• Lead accreditation and survey readiness efforts, including tracer activities, mock surveys, survey coordination, issue clarification, and development of action plans in collaboration with departmental and physician leaders.
• Oversee quality reporting and performance improvement activities, ensuring data integrity, regulatory compliance, and identification of data‑driven opportunities for clinical and operational improvement.
• Provide subject matter expertise and education to leaders, physicians, and staff on regulatory standards, quality improvement methodologies, patient safety practices, and high reliability principles.
• Evaluate, design, and continuously improve the Quality Improvement and Patient Safety Programs in alignment with national trends, best practices, and evolving regulatory expectations.
• Lead patient safety initiatives, including facilitation of Root Cause Analyses and Failure Mode and Effects Analyses, and oversight of patient safety and quality improvement committees.
• Partner with system and organizational stakeholders, including transformation and performance improvement teams, to support change management, high reliability organizing, and sustainable improvement.
• Provide day-to-day leadership and oversight of quality, safety, and regulatory functions, including direct supervision of quality team members, Patient Safety Coordinator, Infection Prevention, and Clinical Informatics Analyst; establish departmental goals, manage performance, and foster a culture of learning and accountability.
• Oversee policy management and governance processes, ensuring organizational policies are current, compliant, and effectively implemented in partnership with process owners.
• Provide administrative and operational leadership for quality, safety, and regulatory teams, including staff development, goal setting, budget management, and fostering a culture of accountability, learning, and continuous improvement.
• Perform all other duties as assigned.

Education & Experience - Required

• Master’s degree in health care or business-related field
• Five years health care experience in a clinical discipline, including at least three years quality, safety, and regulatory affairs experience and/or operations leadership experience (or equivalent)

Education & Experience - Preferred

• State of Maryland clinical licensure
• CPHQ and CPPS certification

Knowledge, Skills, & Abilities

• Knowledge of accreditation standards, Medicare Conditions of Participation, patient safety science, and State licensure regulations.
• Advanced oral and written communication skills; demonstrated skill in collaborating effectively with team members, peers, and executive management
• Ability to challenge and debate issues of importance to the organization, including looking at situations from different viewpoints
• Advanced knowledge of applicable regulatory and accreditation standards, requirements, and issues in health care.
• Ability to effectively delegate responsibilities
• Skill in using a variety of operations performance improvement techniques such as Lean and Six Sigma.
• Experience and advanced skill in facilitating groups
• Strong skills in data analysis and display
• Project management and problem-solving skills