Director of Quality

  • HCA
  • Salem, VA 24153, USA
  • Sep 29, 2017

Job Description

Job Code: 00005-18440


No Weekends

For more than 100 years the LewisGale name has been synonymous with high-quality, compassionate healthcare. Today, our unwavering commitment to our patients ranks us as one of the top hospitals in Virginia and the nation for quality of care including patient safety, patient satisfaction and health outcomes. Our growing integrated network of care includes four hospitals, six outpatient centers, two cancer centers and 700 physicians at more than 160 affiliated locations stretching from Alleghany Highlands and Rockbridge County to the Roanoke and New River Valleys.

Our parent company, Hospital Corporation of America (HCA) , is headquartered in Nashville, Tennessee, and is the nation's leading provider of healthcare services, with hundreds of hospitals and freestanding surgery centers in 20 states and England. LewisGale is part of HCA's Capital Division .


  1. Provides direction for the hospital wide Quality Assessment/Performance Improvement Program including design, implementation, monitoring and evaluation. Provides oversight for Medical Staff QA/PI program including coordinating peer review activities and ensuring availability and assessment of comparative quality data as available for credentialing activities
  2. Serves as an internal consultant to all departments related to accrediting and regulatory requirements including TJC, CMS, State hospital licensure, and state/local health department surveys. Ensures continual survey readiness activities by providing ongoing educational opportunities for staff, medical staff, and management staff.
  3. Completes QA/PI reporting requirements according to facility wide PI plan. Presents data accurately, appropriately, and timely to Senior Leadership, Medical Staff, and Board of Trustees. Ensures data is disseminated and explained to relevant hospital staff for cross-departmental coordination of PI activities.
  4. Provides direction for internal quality initiative activities and ensures all deadlines are met including third party payer incentive plans, Leapfrog, Hospital Quality Alliance (CMS), National Database for Nursing Quality Indicators (NDNQI), and Virginia Health Quality Center collaboratives. Ensure participation in all HCA recommended quality initiatives not included above.
  5. Responsible for preparation and management of the capital and operational budget for Quality and other assigned departments. Ensures direct reports have current job descriptions, employee evaluations and current policy & procedures as applicable.
  6. Oversees quality measurement, public reporting, and pay-for-performance programs and initiatives, holding staff and departments accountable for achieving performance goals.
  7. Coordinates closely with clinical information technology and health information management to achieve organizational goals. Promotes a culture of safety, high-reliability, patient and staff engagement, and performance excellence.

Required - Five years of current experience in nursing. Strong record of leadership, project management and collaboration. Demonstrated analytic and computer skills including use of statistical process control charts, with strong writing, problem solving, and communication skills.

Preferred - Three years management experience with quality experience. Knowledgeable and experienced in Lean, Six Sigma, PDSA or other performance improvement methods, with record of successful improvement projects.

Required - Current Virginia licensure by the State Board of Nursing as a Registered Professional Nurse. BSN
Preferred - Specialty Certification, Masters' Degree.

Last Edited: 09/27/2017