Director of Quality, Accreditation and Compliance

The USC Neurological Hospital is seeking to hire a Director of Quality, Accreditation and Compliance to join our team.

The Director of Quality, Accreditation and Compliance provides strategic leadership and operational oversight for the hospital’s quality management, patient safety, regulatory compliance and accreditation programs. This role is accountable for ensuring safe, effective, and patient‑centered care through continuous performance improvement, regulatory readiness, and accreditation compliance. The Director leads organization-wide initiatives that strengthen regulatory compliance, reduce organizational exposure, and enhance operational reliability while promoting a culture of excellence, transparency, and Just Culture.

Working collaboratively with clinical and administrative leaders, this position drives the development, implementation, and monitoring of quality systems, policies, and performance measures to ensure alignment with organizational goals, regulatory requirements, and national best practices.

Job Related Minimum Required Education and Experience:

• Requires a bachelor’s degree in a job related field and at least 8 years of job related experience, including some prior management experience.

Required Certification, Licensure/Other Credentials:

• Professional certification in quality, safety, infection prevention, or process improvement (e.g., CPHQ, CPPS, CIC, CQM).

Preferred Qualifications:

• Clinical Degree strongly preferred or master’s degree in healthcare administration, Nursing, or a related field
• Minimum of ten (10) years of progressive leadership experience in acute care quality management, quality assurance, risk management, or regulatory compliance.
• Six Sigma Green Belt or Black Belt and/or Project Management Professional (PMP) certification.
• Demonstrated experience leading large‑scale performance improvement initiatives within complex healthcare organizations.
• Extensive knowledge of hospital clinical operations, patient safety principles, infection prevention, risk management, and regulatory requirements.

Knowledge/Skills/Abilities:

• Proven ability to build strong internal and external relationships and work effectively across multidisciplinary teams.
• Strategic thinker with the ability to develop and execute short‑ and long‑term quality and safety improvement plans.
• Demonstrated success leading organizational change through influence rather than authority.
• Strong knowledge of healthcare regulations, accreditation standards, improvement methodologies, payer programs, and emerging healthcare trends.
• Ability to lead through uncertainty, establish Just Culture principles, and create psychological safety.
• Expertise in performance improvement methodologies and tools, with the ability to manage multiple projects simultaneously while coaching others.
• Strong analytical, communication, and presentation skills.
• Proficiency in Microsoft Word, Excel, PowerPoint, Visio, and database systems.

Job Duty: Quality Management & Performance Improvement

• Lead the design, implementation, and oversight of quality management and performance improvement programs across hospital operations and affiliated clinical programs, ensuring alignment with national, state, and local standards. Develop and monitor quality initiatives focused on reducing clinical variation, preventing harm, improving patient outcomes, and sustaining accreditation compliance (e.g., CMS, CIHQ).
• Oversee the collection, analysis, validation, and reporting of core measures, electronic clinical quality measures (eCQMs), Meaningful Use metrics, and IQR/OQR programs.
• Establish and maintain quality dashboards and analytic tools to monitor performance, identify trends, and guide data‑driven decision making.
• Partner with clinical and operational leaders to implement evidence‑based practices and sustain measurable improvements in care delivery.

Essential Function: Yes

Percentage of Time: 20

Job Duty: Patient Safety & Quality Improvement

• Provide leadership for patient safety to proactively identify, prevent, and mitigate clinical and operational risk.
• Lead and/or oversee root cause analyses (RCAs), failure mode and effects analyses (FMEAs), and other safety event investigations.
• Ensure timely development, implementation, and monitoring of corrective action plans resulting from adverse events, near misses, and safety concerns.
• Promote and model a Just Culture framework that supports open reporting, learning from error, and psychological safety.
• Foster a non‑punitive environment where staff are encouraged to speak up, escalate concerns, and engage in meaningful quality improvement.

Essential Function: Yes

Percentage of Time: 20

Job Duty: Regulatory Compliance & Accreditation

• Provide enterprise leadership oversight for regulatory compliance and continuous accreditation readiness across all departments.
• Serve as the organizational lead for accreditation surveys, regulatory audits, and site visits, including coordination of preparation activities and follow‑up actions.
• Ensure timely, accurate, and complete submission of all required regulatory and quality reporting.
• Monitor regulatory changes and emerging standards, advising leadership on compliance risks and strategic response.

Essential Function: Yes

Percentage of Time: 20

Job Duty: Data Analytics, Reporting & Governance

• Lead enterprise quality data governance, including metric selection, performance targets, and standardization of reporting.
• Analyze clinical and operational data to identify trends, gaps, and opportunities for improvement.
• Prepare and present quality, safety, and compliance reports to senior leadership, medical staff, and the executive leadership.
• Translate complex data into clear, actionable insights that support operational improvement and strategic decision making.

Essential Function: Yes

Percentage of Time: 20

Job Duty: Leadership & Collaboration

• Build strong partnerships with physicians, nursing leaders, department managers, and executive leadership to advance quality and safety goals.
• Influence change across disciplines through collaboration, coaching, and effective communication.
• Lead, mentor, and develop quality and risk staff, fostering professional growth and accountability.
• Support organizational initiatives related to safety culture, health equity, patient experience, and population health, as applicable.

Essential Function: Yes

Percentage of Time: 20