Responsible for managing the Quality management function, core measures compliance, patient satisfaction, and collaborating with clinical service lines in carrying out performance improvement projects/initiatives. Work requires strong clinical nursing expertise and an understanding of patient care standards/practices and applicable regulatory requirements sufficient to facilitate and maximize core measure achievement and patient satisfaction scores. This position is responsible for ensuring that the facility is in compliance with TJC, state and federal standards. The position has oversight responsibility for all regulatory body surveys, i.e., TJC, State Licensing Review, CMS Validation surveys. This includes staying current with TJC standards, educating facility staff about TJC standards, preparing the facility for TJC accreditation surveys. Responsible for planning and implementing the performance improvement program