Director of Quality Improvement

Full Time
Full Time

Performs the functions of Director of Quality Improvement under the direction of the Chief Medical Officer (CMO) in accordance with Joint Commission and health center administration medical staff goals and the approved Quality Assessment/Improvement Plan. To monitor unusual occurrences, report follow-up procedures, and report monthly and year-to-date comparisons.

  • Performs quality-improvement function to accomplish health center wide coordination, monitoring, and reporting of quality-improvement studies, programs and analysis according to the QA/PI plan.
  • Responsible for knowing current QA regulations and informing the CMO of any new and/or revised regulations imposed.
  • Assists departments with the coordination of audit information, and recommends appropriate data-gathering mechanisms, procedures, etc.  Attends meetings as requested, in particular the monthly QA/QI meeting at which serves as recorder and coordinator.
  • Attends meetings as requested, in particular the monthly QA and PI meetings at which DQI serves as recorder and coordinator.
  • Responsible for achieving a satisfactory working environment between other departments performing quality-improvement studies, and assisting when necessary with the accumulation, display, routing, and dissemination of the information to appropriate committees, physicians, and departments.
  • Assists the CMO with revisions to the QA/QI and Performance Improvement plan for board and staff review.
  • Keeps the DCMO informed of studies in process and progress thereof, committee agenda items; discusses problems and completion of audit procedures.
  • Gathers information and documentation about unusual occurrences; assists with the identification of problems through statistical information, monitoring, and reporting results of action taken to reduce risks to patients. Provides information to employees and visitors when necessary.
  • Actively participates in Health Quality Initiatives and the development of programs surrounding new models of health care, internally and as appropriate in the Trenton community.
  • Performs other duties as assigned by the CMO.


  • Work is varied in nature and is performed with frequent interruptions. Work requires close attention to detail and accuracy. 0ccasional mental stress is involved in completing QA activities with regard to physicians and departments and interrelationships.
  • Work requires sitting, standing, and/or walking, moving and reading for periods of three hours or more.


  • Knowledge and understanding of the coding abstracting system used in the Medical Records Department for efficient data gathering.
  • Knowledge of accreditation standards applicable to the medical staff. QA/QI committee activities and Medical Records Department.
  • Ability to interpret Medical Records policies and procedures and to apply them in specific situations.
  • Thorough knowledge of Joint Commission quality-assurance requirements.


  • Bachelors or Master’s degree preferred and current licensure, as applicable, in nursing, public health or equivalent. A minimum of five-seven years’ related work experience in quality management, risk management areas. Demonstrated successful supervisory experience of three-five years required.
  • Some practical experience in the field; knowledge of medical diagnoses and treatment helpful.

Henry J. Austin Health Center is an Equal Opportunity Employer (EOE). Qualified applicants are considered for employment without regard to age, race, creed, color, national origin, ancestry, marital status, civil union, domestic partnership, affectional or sexual orientation, genetic information, sex, gender identity, disability or veteran status