Director of Quality Standards

  • HCA
  • Nashville, TN, USA
  • Jan 31, 2018

Job Description

Job Code: 10201-23196


Days (rotating weekends)

About HCA

Nashville-based HCA is one of the nation's leading providers of healthcare services, operating 171 locally managed hospitals and 119 freestanding surgery centers in 20 states and the United Kingdom. With its founding in 1968, HCA created a new model for hospital care in the United States, using combined resources to strengthen hospitals, deliver patient-focused care and improve the practice of medicine. HCA has conducted a number of clinical studies, including one that demonstrated that full-term delivery is healthier than early elective delivery of babies and another that identified a clinical protocol that can reduce bloodstream infections in ICU patients by 44 percent. HCA is a learning healthcare system that uses its more than 27 million annual patient encounters to advance science, improve patient care and save lives.

About CSG

The Clinical Services Group (CSG) is responsible for establishing HCA Clinical Strategic Priorities for HCA to be the recognized leader in care delivery achieving world class outcomes. The CSG purpose is to drive excellent care at scale.

Job Summary

Quality Standard Department's primary purpose is to promote safe, high quality and effective patient care through maintaining accreditation, certification and licensure compliance of all facilities. HCA Clinical Strategies and Regulatory compliance are foundational to the work of the Quality Standards Department.

To provide consultation and education to HCA facilities regarding clinical performance improvement and foundational standards of operational compliance including the Joint Commission/AAAHC, Centers for Medicare and Medicaid Services (CMS), and other health care standard setting and enforcement entities. Manager is a role of knowledge building towards responsibility for surveys for HCA Quality Review System as a Director, Quality Standards.

Travel to provide onsite expert consultation and survey for HCA Quality Review System to HCA hospital and ASC Administrator/Chief Executive Officers, Chief Nursing Officers and other hospital/ASC, Board of Trustee and medical staff leaders regarding clinical performance improvement and foundational operational standards requiring facility compliance. Role is critical to HCA strategy of Quality and Patient Safety as a differentiator of hospital and ambulatory surgery center operational performance. Role complements and provides guidance to Division Vice President, Quality or Director, Quality and Risk Management.

Individual serves as the expert consultant to hospital and ASC clinical performance improvement. Position requires expertise to guide hospital/ASC quality and risk directors in their position requirements and to counsel CEO/Administrator, CNO, COO, medical staff and board leaders in continuous patient care improvement in a foundationally compliant manner. With increasing HCA Clinical Improvement patient quality agenda, this position is critical to HCA mission and strategies.

Position requires competencies for performance with with senior department member for training and assurance of knowledge acceptable a level of director. Incumbent travels and provides consultation but always with a Senior Director or AVP until expert knowledge is demonstrated.

To design and present educational programs for HCA hospital/ASC and medical staff leaders regarding requirements of clinical performance improvement for operational compliance to public reporting including the hospital quality alliance, external quality agencies including the Joint Commission/AAAHC, CMS, State Survey agencies, etc.

To conduct onsite assessments of focused topics within HCA hospitals/ASCs including credentialing, utilization management, peer review, medical staff and board bylaws, etc.

Position demands a total command of clinical performance improvement, Clinical Excellence, HCA Clinical Agenda, TJC and AAAHC standards, healthcare licensure regulations and CMS conditions of participation/coverage. Position is critical to advancement of HCA facility delivery of safe, effective, efficient, compassionate and satisfying patient care as defined by the HCA Clinical Improvement Strategies.


  • 7 plus years of related experience
  • College Degree Required. Registered Nurse, Registered Pharmacist, Registered or Accredited Health Information Administrator, Healthcare Administrator or other healthcare professional
  • Consulting and educational program delivery skills and expertise
  • Computer knowledge and competency for presentation design and report delivery
  • Expert speaking and presentation skills and competency
  • Must be a team participant focused toward HCA clinical improvement strategies
  • Long term position commitment required.
  • 80% travel, 12-14 hour consulting days

Bachelor's Degree

Last Edited: 01/31/2018