Director of Quality, Safety, Compliance, and Risk

About Us:
Grand Traverse Pavilions is a premier healthcare facility dedicated to providing exceptional care to our residents. We are committed to maintaining the highest standards of safety, quality, and ethical care. Our team-oriented environment allows leaders to make a meaningful impact on resident outcomes while supporting a culture of continuous improvement.

Job Summary:
As the Director of Quality, Safety, Compliance, and Risk, you will provide strategic leadership in the development, implementation, and oversight of our Quality Assurance and Performance Improvement (QAPI), compliance, risk management, and ethics programs. You will play a key role in fostering a culture of safety, ethical standards, and operational excellence, ensuring the well-being of residents and compliance with all federal and state regulations.

Key Responsibilities:

Quality Assurance & Performance Improvement (QAPI)

• Lead and coordinate the facility’s QAPI Committee and monthly meetings.
• Analyze departmental performance data to identify high-risk areas and implement performance improvement projects (PIPs).
• Develop, monitor, and communicate key performance indicators (KPIs) and standardized processes across departments.
• Conduct rounds and collaborate with teams to identify vulnerabilities and improvement opportunities.
• Maintain comprehensive documentation of QAPI activities for regulatory review.

Compliance

• Ensure compliance with all federal, state, and local regulations, including Medicare, Medicaid, LARA, and CMS standards.
• Integrate compliance into all aspects of operations and provide training to staff and volunteers.
• Investigate compliance issues and coordinate corrective actions.
• Participate in regulatory reporting and survey readiness, supporting facility-wide compliance initiatives.

Ethics & Risk Management

• Oversee adherence to the facility’s ethics and compliance program.
• Implement internal reporting systems for suspected violations and ethical concerns.
• Lead risk assessments, incident investigations, and post-fall huddles to minimize future hazards.
• Collaborate with legal counsel, insurance providers, and leadership to resolve ethical and legal matters.

Safety & Accident Prevention

• Ensure a safe environment for residents and staff, addressing hazards proactively.
• Conduct safety inspections, oversee maintenance of patient care equipment, and enforce ergonomics and safety protocols.
• Participate in committees related to safety, risk, falls prevention, and resident well-being.

Qualifications:

• Bachelor’s degree in Nursing; Master’s degree in a related field preferred.
• Valid RN license in the State of Michigan.
• Experience in QAPI, risk management, safety, quality improvement, and compliance.
• Knowledge of state (LARA) and federal (CMS) regulatory requirements for long-term care.
• Strong leadership, communication, critical thinking, and analytical skills.
• Ability to coach, educate, and influence staff at all organizational levels.
• Specialized training or experience in gerontology preferred.

Working Conditions:

• Exposure to busy healthcare environments, including noise and frequent interruptions.
• Responsible for ensuring compliance with safety protocols and ethical standards.
• Interaction with multidisciplinary teams, leadership, and external regulatory agencies.

Why Grand Traverse Pavilions?
Join a team that values excellence, integrity, and innovation. We offer a collaborative environment, opportunities for professional growth, and a supportive culture focused on delivering the highest standard of care to our residents.

Grand Traverse Pavilions is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.

Please visit our careers page to see more job opportunities.