Director, Quality Assurance/Quality Improvement

Position Summary

The Director of Quality is responsible for leading and coordinating the hospital’s Quality Assurance and Performance Improvement (QAPI), Risk Management, and Infection Control programs. This role ensures compliance with regulatory standards while driving continuous improvement in patient care, safety, and organizational performance. The Director also supports staff education initiatives and serves as a key liaison with regulatory agencies.

Key Responsibilities

• Lead and coordinate the hospital’s Quality Assurance and Performance Improvement (QAPI) program

• Oversee Risk Management processes, including incident reporting, investigation, and follow-up

• Direct and monitor Infection Control practices, surveillance, and prevention initiatives

• Analyze data to identify trends, opportunities for improvement, and sustain performance outcomes

• Ensure compliance with regulatory requirements, including CMS, LDH, and TJC standards

• Prepare and present quality and infection control reports, including monthly statistics

• Collaborate with leadership to implement performance improvement plans

• Serve as liaison with regulatory agencies, including LDH and Public Health Department

• Oversee reporting and follow-up of abuse, neglect, and other reportable incidents

• Ensure compliance with life safety, fire codes, and environmental safety standards

• Support staff education by identifying learning needs and developing training programs

• Maintain and update Quality, Risk Management, and Infection Control policies and manuals

• Enter and manage QAPI data in required reporting systems

• Function as Compliance Officer for the organization

• Perform other duties as assigned

Education & Licensure

• Graduate of an accredited school of nursing

• Current, unrestricted Registered Nurse (RN) license in the State of Louisiana

Experience Requirements

• Minimum of three (3) years of progressive experience in acute care or psychiatric care preferred

Knowledge, Skills & Abilities

• Strong knowledge of QAPI processes, Risk Management, and Infection Control practices

• Working knowledge of regulatory standards including CMS, LDH, and TJC

• Ability to analyze data, identify trends, and drive performance improvement initiatives

• Excellent leadership, communication, and organizational skills

• Ability to collaborate effectively with multidisciplinary teams

Travel Requirements

• Minimal / Rare travel required

Why Join Seaside Health System?

At Seaside Health System, we are committed to providing high-quality, patient-centered care in a safe and supportive environment. Join our team and play a key role in advancing quality, safety, and excellence across our organization.

Equal Employment Opportunity

Seaside Health System is committed to the principle of Equal Employment Opportunity for all employees and applicants. It is our policy to ensure that both current and prospective employees are afforded equal employment opportunity without consideration of race, religious creed, color, national origin, nationality, ancestry, age, sex, marital status, sexual orientation, or disability in accordance with local, state and federal laws.

Americans with Disabilities Act

Applicants as well as employees who are or become disabled must be able to perform the essential job functions either unaided or with reasonable accommodation. The organization shall determine reasonable accommodation on a case-by-case basis in accordance with applicable law.