Director of Quality, Risk Management, Infection Prevention & Employee Health Shift:

(5) 8 hour day shift.

Placement Type:

Direct Hire Reports to: DON Role Overview The Director of Quality, Risk Management, Infection Prevention, and Employee Health is responsible for the development, implementation, oversight, and continuous improvement of CCMSD's Quality Assurance and Performance Improvement (QAPI) Program, Risk Management Program, Infection Prevention and Control Program, Employee Health Program, patient safety initiatives, and regulatory compliance activities. This position promotes a culture of safety, quality, accountability, and continuous improvement throughout the organization, including Acute Care, Long Term Care, Clinics, EMS, and ancillary departments. The Director collaborates with leadership, providers, and staff to support compliance with applicable federal and state requirements and CCMSD policies. Essential Duties and ResponsibilitiesQuality & Performance Improvement

• Direct and oversee the organization-wide Quality Assurance and Performance Improvement (QAPI) Program.
• Develop and monitor quality metrics, scorecards, dashboards, and performance indicators.
• Analyze and report quality outcomes, trends, and opportunities for improvement.
• Facilitate root cause analyses, performance improvement projects, and corrective action plans.
• Coordinate regulatory surveys, audits, and quality reviews.
• Lead quality committees and provide reports to executive leadership and the Board of Trustees.
• Promote evidence-based practices and continuous process improvement across all service lines.
• Monitor the effectiveness and sustainability of improvement initiatives. Risk Management & Patient Safety
• Direct the organization's Risk Management Program and patient safety activities.
• Coordinate review and investigation of patient, employee, visitor, and organizational incidents.
• Oversee event reporting, escalation, corrective actions, and follow-up processes.
• Conduct risk assessments and identify organizational vulnerabilities.
• Analyze adverse events, near misses, claims, grievances, and safety concerns.
• Collaborate with department leaders to develop and monitor risk mitigation strategies.
• Maintain organizational readiness for regulatory reviews and compliance inspections.
• Promote a culture focused on safety, accountability, transparency, and learning. Infection Prevention & Control
• Serve as the organizational lead for Infection Prevention and Control activities.
• Coordinate Annual Vaccinations for LTC residents.
• Maintain an active surveillance program to identify, investigate, prevent, and control healthcare-associated infections and communicable diseases.
• Monitor infection rates, trends, outbreaks, and epidemiological concerns.
• Oversee infection prevention policies, procedures, risk assessments, and annual program evaluations.
• Coordinate outbreak preparedness, response, recovery, and required reporting activities.
• Provide infection prevention education for staff, providers, volunteers, students, contractors, and other applicable personnel.
• Monitor hand hygiene, Standard and Transmission-Based Precautions, PPE use, isolation practices, and environmental infection prevention activities.
• Coordinate required reporting to NHSN and other applicable reporting systems.
• Provide consultation regarding infection prevention concerns. Employee Health
• Direct and oversee the Employee Health Program.
• Manage employee immunization, tuberculosis screening, exposure management, and occupational health processes.
• Coordinate employee health surveillance and communicable disease monitoring.
• Assess or coordinate return-to-work eligibility and infectious disease exposure guidance.
• Support compliance with OSHA requirements, including the Bloodborne Pathogens Standard.
• Collaborate with Human Resources and department leadership regarding employee health, workplace safety, and applicable work restrictions.
• Develop employee health, infection prevention, and occupational health education.
• Maintain confidential employee health documentation in accordance with applicable requirements. Compliance & Regulatory Readiness
• Monitor compliance with applicable federal, state, and local requirements and internal policies.
• Coordinate policy review, revision, approval, and implementation of activities within assigned areas.
• Assist leadership and departments with survey and audit preparation.
• Monitor corrective action plans resulting from audits, investigations, or survey findings.
• Maintain required documentation, reports, and compliance records.
• Provide education to leaders and staff regarding quality, risk, infection prevention, employee health, and regulatory expectations. Leadership Responsibilities
• Lead multidisciplinary committees related to quality, infection prevention, employee health, risk management, patient safety, and compliance.
• Provide consultation, education, and guidance to managers and department leaders.
• Prepare reports for executive leadership, applicable committees, and the Board of Trustees.
• Foster a culture of continuous improvement, patient safety, employee safety, and regulatory readiness.
• Serve as a resource during emergencies, disasters, outbreaks, and public health events. EducationRequired
• Bachelor's degree in Nursing, Healthcare Administration, Public Health, Clinical Science, or a related healthcare field. Preferred
• Master's degree in Nursing, Healthcare Administration, Public Health, Business Administration, or a related field.

Licensure / Certification

Required

• Current Wyoming professional license, if applicable to the individual's discipline.
• Certification in Infection Control (CIC) within two years of hire or as approved by leadership.
• Basic Life Support (BLS). Preferred
• Certified Professional in Healthcare Quality (CPHQ).
• Certified Professional in Healthcare Risk Management (CPHRM).
• Lean Six Sigma or other performance improvement certification. ExperienceRequired
• Minimum five (5) years of progressive healthcare experience.
• Minimum three (3) years of experience in leadership, quality, infection prevention, risk management, employee health, or regulatory compliance. Preferred
• Experience in a Critical Access Hospital, Rural Health Clinic, Long Term Care facility, or integrated rural healthcare system. Knowledge, Skills, and Abilities
• Knowledge of CMS Conditions of Participation and applicable healthcare regulations.
• Knowledge of WY State Nursing Home Rules and Regulations.
• Knowledge of CDC infection prevention guidance and OSHA occupational health requirements.
• Understanding quality improvement and risk management methodologies.
• Ability to analyze data and communicate meaningful findings and recommendations.
• Strong leadership, communication, presentation, project management, and organizational skills.
• Proficiency with electronic reporting systems, quality dashboards, and standard office software.
• Ability to maintain confidentiality, exercise sound judgment, and work collaboratively across departments. Physical Requirements
• Ability to sit, stand, walk, bend, and lift up to 25 pounds occasionally.
• Ability to travel between facility locations as necessary.
• Ability to use standard office and healthcare equipment.
• Reasonable accommodations may be made to enable qualified individuals to perform the essential functions of the position.

Expectations All employees are expected to support our mission, vision, and values while maintaining high standards of patient safety, employee safety, quality care, infection prevention, regulatory compliance, confidentiality, professionalism, and service excellence.

Pay:

$43.00 - $58.00 per hour

Benefits:

401(k) matching Health insurance Referral program

License/Certification:

Infection Control Certification (Required)

Work Location:

In person