JOB TITLE

Director of Quality, Risk, and Compliance

POSITION SUMMARY

The Director plays a critical role in cultivating a culture of patient safety, continuous improvement, and regulatory excellence to ensure the highest standards of care for the community. This position leads the organization's quality, risk, and compliance programs, partnering closely with clinical and operational leaders to strengthen performance and drive measurable improvements in patient outcomes. The Director oversees the development, implementation, and evaluation of key quality initiatives, ensuring strict adherence to regulatory requirements and accreditation standards. This includes identifying trends, prioritizing improvement opportunities, and guiding hospital departments in the execution of effective corrective actions. Serving as a strategic resource, the Director provides expert leadership and consultative support to hospital and medical staff in achieving regulatory success and maintaining organizational compliance across all quality improvement activities. This role also manages the coordination of certification standards and survey readiness, including the drafting and revision of policies and procedures related to quality, compliance, and risk management. The ideal candidate brings extensive experience in survey preparation and functions as a Subject Matter Expert in quality, championing a strong culture of safety and operational excellence throughout the organization.

ESSENTIAL FUNCTIONS

Build Trust:

We exhibit integrity, transparency and compassion in every interaction. Oversee patient complaints and grievance processes ensuring compliance, documentation, follow‑up, service recovery, and improvement. Investigate and address incident reports resolving care issues and recommending prevention strategies. Ensure confidentiality of all quality‑related data and provide accurate reports to the Board of Commissioners and leadership Respond to and prepare information for public record requests. Develop and direct strategies for Compliance including HIPAA investigations, auditing, the organizational Compliance plan, and serving in the Privacy Officer role. Build and maintain strong relationships with stakeholders including patients, families, employees, and regulatory bodies. Ability to function under stressful situations maintaining professionalism and compassion during high‑pressure events.

Obsess Over Excellence:

We have high standards and seek continuous improvement. Maintain and implement the District‑wide Quality Plan ensuring alignment with regulatory standards and organizational goals. Develop and direct strategies for risk management including investigating incidents, training staff, and addressing legal concerns or actions. Assist department managers in identifying improvement opportunities aligned with annual District Quality Goals. Assist managers in event management review selecting effective corrective actions for safety issues. Oversee patient experience processes and metrics ensuring high‑quality, consistent care Serve as a resource for QI initiatives providing leadership, education, and guidance.

Lead Innovation:

We lead with creativity, agility and think bold in our approach. Lead efforts to educate staff on regulations and best practices fostering a learning culture that adapts to evolving standards. Facilitate and chair committees such as the Patient Safety and Quality Metrics Sub‑Committee, driving innovative safety and performance strategies. Develop and direct forward‑thinking strategies for compliance, risk management, and quality improvement. Integrate patient feedback creatively using surveys and data to shape new approaches to care. Managing and developing quality data reporting, both internal and external.

Deepen Connections:

We build strong relationships with our patients, their families and partners in the communities we serve. Oversee and manage Patient Relations ensuring compassionate, responsive communication. Assure the \"voice of our customers\" is incorporated through patient satisfaction surveys and care‑related data. Build and maintain strong relationships with all stakeholders, strengthen trust and collaboration. Oversee patient experience processes ensuring patients and families feel heard, respected, and supported.

QUALIFICATIONS

Required Education:

Bachelor's degree required in Professional clinical discipline, such as, but not limited to, Nursing, Occupational or Physical Therapy, Laboratory etc.

Preferred Education:

Advanced degree desirable in health care administration, quality management, adult learning, or other discipline with emphasis on outcomes assessment and data management.

Specialty Certification Preferred:

CPHQ, Certified Professional Healthcare Quality CPHRM, Certified Professional in

Healthcare Risk Management LEAN Six Sigma Required Experience:

At least 5-years professional healthcare experience At least 3-5-years' experience in quality assurance, quality improvement, or risk management Experience managing quality improvement activities such as process improvement, lean methodologies, quality system assessment Experience interpreting healthcare regulations and accreditation requirements and designing systems to meet them. Experience with customer service and patient relations Survey design as well as interpretation and communication of survey results Proficiency in data management, statistical methods, and effective communication across all organizational levels Preferred experience working for a Public Hospital District/Critical Access Hospital and CMS certified Rural Health Clinic Preferred experience with public record requests.

Skills:

Strong ability to maintain confidentiality, navigate complex situations, and express ideas effectively to groups. Experience utilizing

EPIC EMR

Group facilitation skills required Strong communication skills both written and verbal. Demonstration of strong strategic and change management leadership. Demonstrated ability to work with cross functional teams to achieve organizational objectives. Ability to effectively interact with patients and families and deescalate stressful situations Problem solving and coaching in a team environment Computer skills including Microsoft Word, Microsoft Excel, Microsoft Visio, and on-line database management

WORK ENVIRONMENT

Office and clinical settings with potential exposure to patient care areas. Flexibility to work extended hours as needed.

PHYSICAL DEMANDS

Ability to work in a fast-paced environment and handle multiple priorities. May require occasional travel between facility locations.

OTHER DUTIES

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

BENEFITS

We believe in taking care of those who take care of our community. We're proud to offer a comprehensive benefits package that puts your health and well-being first. With our flexible medical plan, you'll have access to multiple in-network tiers, including top-quality care from Snoqualmie Valley Health, Eastside Health, and First Choice/First Health providers. The best part? Anyone covered under our plan can receive care at SVH at no cost! It's all about giving you the options and support you need to experience life's great adventures. Medical Dental Vision Pharmacy Life and AD&D Retirement Plan Employee Assistance Program (EAP) Flexible Spending Account (FSA) Travel Assistance & ID Theft Protection Pet Insurance Other Voluntary Benefits Benefit Eligibility Requirements

Employees regularly scheduled at least 20 hours per week. Employee Dependents
Your legal spouse or domestic partner; dependent children until age 26. Waiting Period
1st of the month from the date of hire.

PLEASE NOTE

The flu shot (during flu season) is required for employment, with exemptions available for valid medical or religious reasons. Snoqualmie Valley Health is a drug-free workplace. 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Director of Quality, Risk, and Compliance (On Site )