Regional Dir-Qual Improvement

York, PA | Professional | Tracking Code: 71990

General Summary: 

Under the general direction of the Senior Director-Quality, provides leadership and oversight of the hospitals based in the assigned scope to improve quality, implement clinical initiatives, direct performance improvement and promote innovation.  Identifies, develops and directs implementation of best practices for clinical excellence and patient care quality for the scope.  Offers strategic direction and leadership to achieve quality excellence.  Expert at national quality measures and related accreditation requirements.  Leads, coordinates and connects System quality plan and reporting, and initiatives and planning for the scope, directing and supervising all dedicated hospital quality/quality improvement staff.  Supports the purpose of the Quality Model.  Establishes connections, in the areas of quality, accreditation, patient safety and infection control, within the WellSpan Health (WSH) system quality structure, Quality Council and the WSH regions and entities.  Ensures a standardized communication process for strategy and engagement.  Develops a broader skill pool for staffing coverage, training, professional development, collaborative work efforts, team development and employee satisfaction.  Creates a model design that bridges multiple entities within a geographical region for easier identification of process/policy gaps and differences and related reporting and discussion with the goal of continuous improvement and early identification of risk.  Identifies, determines and implements best practice(s) for clinical/operational support.  Shares and spreads best practice processes, using Lean methodology inclusive of A3 problem solving, LDM improvement methodology, and standard work.  Acts as dedicated Quality Leader for hospitals/entities in the region, working with the Regional Director of Accreditation and the Hospital based Medical Affairs Vice Presidents (VPMA) in quality program direction and design.  Responsible for that hospital’s specific quality work including, but not limited to, the Quality Committee agenda and related Quality and Performance Improvement plan for the hospital. 


Duties and Responsibilities: 


1 Provides direction and supervision of all dedicated hospital quality staff operating under Corporate Quality. 

2 Provides System direction and coordination of the quality activities for the hospitals within their scope. 

3 Communicates system work regarding quality improvement and integrates system focus and report planning into quality improvement initiatives. 

4 Coordinates and communicates with WellSpan Health hospitals regarding quality measure/metric/requirement notices and changes.   

5 Develops or revises policies and procedures necessary to support quality improvement. 

6 Develops and coordinates regional educational initiatives to ensure appropriate quality interpretation.  Assists with education efforts of the Hospital's/System's employees regarding quality related activities. 

7 Works collaboratively with hospital leadership, physicians, nursing, ancillary staff, and other key departments such as Clinical Improvement, Performance Improvement, Patient Safety, Population Health, Data Analytics, Infection Control, Patient Experience, Accreditation/Compliance, WSH Medical Group and Summit Medical Group staff, Regional Medical Directors, CNOs and VPMAs.   

8 Supports the development of updates, revisions, monitoring, reporting and submission for approval of the Quality Improvement Plan for each hospital within their scope. 

9 Supports the Quality Improvement Committees for the hospitals within their scope. 

10 Promotes and adheres to the Code of Conduct and the elements of the Corporate Compliance program and exercises due diligence to ensure compliance with policies and legal requirements.   

11 Reviews, analyzes and coordinates reporting for Hospital quality metrics, inclusive of all dashboard metrics. 

12 Works collaboratively with Quality and Accreditation Director and team for innovative data solutions to move data reporting more concurrently and eliminate manual (chart) review where possible. 

13 Assists with quality of care complaint process as required. 

14 Acts as a dedicated quality resource and subject matter expert for hospitals/entities in their scope.. 

15 Directs activities in line with the Inpatient/Outpatient Quality continuum.   

The following are common expectations: 

16 Maintains established policies and procedures, objectives, quality assessment, safety, environmental and infection control standards. 

17 Enhances professional growth and development through participation in educational programs, current literature, in-service meetings, and workshops. 

18 Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation. 




Note: Other combinations of formal education, training and experience may be considered. 


Minimum Education: Bachelor’s Degree 


Preferred Education: Master’s Degree or MBA 


Minimum Experience:  More than 5 years’ experience in health care and health care system administration, and in roles of progressive healthcare quality leadership/management responsibility.  Experienced with the national guidelines that produce quality measures and accreditation standards and the related audit processes. 


Min Field Of Expertise Health care system administrative expertise 


Pref Cert/Registration: Registration and current RN license in PA; CPHQ 


Skills: Other Microsoft Office expertise 


James Kane
James Kane
Sr. Talent Acquisition Consultant
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Why WellSpan Health?

WellSpan Health is an integrated health system that serves the communities of central Pennsylvania and northern Maryland. The organization comprises a multispecialty medical group of more than 1,600 physicians and advanced practice providers, a regional behavioral health organization, a home care organization, eight respected hospitals, more than 20,000 employees and 200 patient care locations. WellSpan is a charitable, mission-driven organization committed to exceptional care for all, lifelong wellness and healthy communities. We are committed to transforming the health of the communities we serve and to educating the next generation of clinicians, staff and leaders.

Employment Benefits

  • Sign-on incentives for new employees (click here for details)
  • Medical, dental and vision insurance
  • Life and accidental death insurance
  • Supplemental life insurance
  • Retirement savings plan
  • Paid time off (PTO)
  • PTO bridging
  • Short-term disability
  • Educational assistance
  • Forgivable loan
  • Flexible spending
  • Credit union
  • Employee recreational activities
  • Childcare
  • Complimentary medicine discounts

Diversity & Inclusion

Welcome. Respect. Value.

Wellspan Health believes that diversity includes all the human characteristics that make each of us similar as well as different. We strive to make every person feel welcomed, respected, and valued while creating a safe and inclusive environment where we all have the individual freedom to express our uniqueness in a respectful manner.

WellSpan Health is an Equal Opportunity Employer. It is the policy and intention of the System to maintain consistent and equal treatment toward applicants and employees of all job classifications without regard to age, sex, race, color, religion, sexual orientation, gender identity, transgender status, national origin, ancestry, veteran status, disability, or any other legally protected characteristic. WellSpan Health does, however, have a tobacco-free/nicotine-free hiring policy.

Quality of Life

Founded in 1741, the city of York is considered by many as the first capital of the United States. The Articles of Confederation were signed by the Second Continental Congress here in 1777. Its beautifully restored historic district is an architectural treasure. While York retains its farming and manufacturing heritage, at its heart York is a thriving cultural community that has attracted creative talent and innovative entrepreneurial investors from across the nation.

Life in York County offers affordable housing, options for higher education, a thriving arts and cultural community, historical attractions, parks and recreational resources, semi-professional baseball team, fine dining and more — within an easy drive of major East Coast cities.

York County residents can find local employment in healthcare, manufacturing, technology, agricultural and service sectors. (Patient population: 445,000)