Director of Quality Improvement and Survey Readiness

About us: For the past 85 years, Stephens County Hospital has been a trusted name in the community, striving for excellence and delivering professional and compassionate care. Our dedicated staff of approximately 475 employees has a heart for healthcare and realizes how precious the gift of good health can be.

Stephens County Hospital is a 96-bed acute care hospital located in Toccoa, Georgia. We are nestled in the beautiful foothills of Northeast Georgia where our family-oriented community offers many cultural and civic opportunities as well as numerous outdoor activities. 

Stephens County Hospital is a member of the Georgia Hospital Association, American Hospital Association and Georgia Alliance of Community Hospitals. Stephens County Hospital is fully accredited by the Joint Commission, the nation’s premier healthcare monitoring agency.

 

Director of Quality Improvment and Survey Readiness  - Full Time

 

Education / Experience:

  • 4 year / Bachelor's Degree in in relevant field (Required)
  • Master's Degree in in relevant field (Preferred)
  • Preferred Certifications/Licensures: Certified Professionals in Healthcare Quality (CPHQ)
  • Lean Six Sigma knowledge/training (preferred)
  • RN with with 5 year’s experience and an active GA license or compact license

 

Duties and Responsibilities:

  • Coordination of prioritization, integration, implementation and evaluation of annual quality plan for the organization.
  • Responsible for coordinating all regulatory and accreditation standards compliance.
  • Coordinate all purchases of related databases for QI in collaboration with IS.
  • Oversight of clinical database systems management.
  • Participates in the annual budgeting process and provides feedback around quality tools, books, etc., necessary for the job. 

 

 

Professional Requirements

 

  • Adhere to dress code, appearance is neat and clean.
  • Complete annual education requirements.
  • Maintain patient confidentiality at all times.
  • Report to work on time and as scheduled.
  • Wear identification while on duty.
  • Maintain regulatory requirements, including all state, federal and local regulations.
  • Represent the organization in a positive and professional manner at all times.
  • Comply with all organizational policies and standards regarding ethical business practices.
  • Participate in performance improvement and continuous quality improvement activities.
  • Attend regular staff meetings and in-services as needed.

 

 

Non-Essential Functions

Perform other duties as assigned or requested.

 

Knowledge, Skills, and Abilities

 

  • Strong organizational and interpersonal skills
  • Ability to determine appropriate course of action in more complex situation
  • Ability to work independently, exercise creativity, and maintain a positive attitude
  • Ability to manage multiple and simultaneous responsibilities and to prioritize scheduling of work
  • Ability to maintain confidentiality of all medical, financial, and legal information
  • Ability to complete work assignments accurately and in a timely manner
  • Ability to communicate effectively, with excellent verbal and written communication skills
  • Knowledgeable and skilled with Microsoft Office to include Word, Excel, Power Point, etc.
  • Knowledgeable of CQI tools and techniques and able to impart that knowledge to others in a manner to obtain compliance.
  • Responsible for organization wide QI reporting to Medical Executive Committee and Department Heads.
  • Coordination of Medical Staff case review and other Medical Staff quality committees in collaboration with Medical Staff Coordinator and Medical Staff.  
  • Oversight of the mandatory reporting of clinical outcomes and process measures to CMS, State QIOs, and accrediting body.
  • Assists with formation/direction of teams. Knowledgeable of state and federal regulations.
  • Designs system to facilitate collection, trending and analysis of data.
  • Serves as internal consultant for those needing assistance with QI initiatives.
  • Assists depts. /service lines in developing key quality indicators and assists in identifying QI opportunities.
  • Coordination of QI education.
  • Provides educational programs to hospital employees, medical staff, and the community regarding topics of QI.
  • Actively seeks opportunities to expand knowledge base through professional development.
  • Knowledgeable of Medical Staff bylaws, rules, and regulations.
  • Assists with Peer Review procedures in conjunction with medical staff.
  • Compiles accurate, timely, and meaningful reports of quality activities. Maintains agendas for assigned committees.
  • Keeps accurate statistical information.
  • Assists chiefs of service with correspondence. Maintains files of credentialing information in an organized manner.
  • Performs selected studies/reviews according to pre-established criteria.
  • Compiles statistical information.
  • Interfaces and collaborates with the Compliance Officer for the purpose of assisting with investigation of potential compliance issues/concerns, record keeping, regulatory readiness and staff education/updates. 
  • Types necessary reports and enters solicited information into database files.
  • Knowledgeable of TJC standards. 
  • Able to interpret standards into policies, procedures, or formation of processes to comply with stated standards.
  • Assists as needed for continuous TJC compliance.

Physical Requirements and Environmental Conditions:

  • Sitting for extended periods of time (up to 4 hour intervals)
  • Must be able to walk, bend, stoop and reach/lift above your head, without any assistive devices. 
  • Must be able to read documentation in a variety of formats such as in print and electronically.
  • Must be able to hear adequately enough in order to clearly communicate with others and use communication devices such as telephones must be able to hear patients, alarms, call bells, etc.
  • Maintains mental and emotional stability, using a courteous and calm approach in all contacts with patients, visitors and healthcare team members.
  • Must be able to lift 10 pounds or more.
  • Have near normal hearing – able to hear alarms/telephone/normal speaking voice/ webinars
  • Have near normal vision – clarity of vision (both near and far) either corrected on non-corrected, ability to distinguish colors
  • Have good manual dexterity and eye-hand-foot coordination
  • Standing – continuously within the shift (67-100%)
  • Walking – continuously within the shift (67-100%)
  • Climbing – occasionally within the shift (1-33%)
  • Bending/stooping – frequently within the shift (34-66%)
  • Twist at the waist – occasionally with the shift (1-33%)
  • Pushing/pulling – frequently within the shift (34-66%)
  • Lift/carry – 20lbs with assistance – occasionally within the shift (1-33%)
  • Reaching above the shoulders – frequently within the shift (34-67%)
  • Lift/carry – 50lbs with assistance – occasionally within the shift (1-33%).

 

Stephens County Hospital is an equal opportunity employer. All applicants will receive consideration for employment without regard to race, color, religion, sex, age, pregnancy, marital status, national origin, citizenship status, disability, military status, sexual orientation, genetic predisposition, carrier status or any other legally protected status.

marie.culver@stephenscountyhospital.com
marie.culver@stephenscountyhospital.com