Director Quality Accreditation and Medical Staff Services

Vitruvian Health•Dalton, GA

1d•Onsite

About The Position

The Director, Quality and Medical Staff Services provides strategic and operational leadership for Hamilton Medical Center's Quality, Patient Safety, Accreditation, Regulatory Compliance, and Medical Staff Services programs. This position is responsible for the development, implementation, evaluation, and continual improvement of systems and processes that promote high-quality, safe, patient-centered care while ensuring compliance with federal, state, and accreditation requirements. The Director leads the organization's quality and safety initiatives, including performance improvement, physician peer review, patient safety, credentialing and privileging, regulatory readiness, and Joint Commission accreditation activities. Leveraging data analytics and evidence-based practices, the Director identifies opportunities for improvement, establishes performance measures, monitors outcomes, and drives sustainable improvements in clinical quality, operational effectiveness, and patient safety. Serving collaborative partner to executive leadership, department leaders, physicians, and Medical Staff, the Director fosters a culture of accountability, continuous improvement, and high reliability. The position provides leadership for organizational survey readiness, mandatory reporting requirements, and regulatory programs while ensuring alignment with strategic goals and industry best practices. The Director oversees the day-to-day operations, staffing, fiscal management, and performance of the Quality and Medical Staff Services departments. As Chair of the Patient Safety Committee and a champion of continuous service readiness, the Director promotes organizational excellence through proactive risk identification, performance improvement methodologies, and interdisciplinary collaboration focused on achieving exceptional patient outcomes.

Requirements

Bachelor's degree required.
Five years broad-based clinical experience and data aggregation and analysis knowledge with at least three years in a management role.
Minimum of three years of experience in quality/risk improvement in healthcare.
Ability to implement, design, and maintain clinical information systems in order to effectively use clinical information solutions to improve upon clinical operations.
Strong knowledge of healthcare quality, patient safety, accreditation, and regulatory requirements.
Effective leadership, communication, conflict resolution, and relationship-building skills.
Proven project management skills with the ability to lead multiple initiatives and achieve measurable results.
Demonstrates professionalism, integrity, sound judgment, and alignment with Hamilton Medical Center's mission and values.
Maintains current knowledge of quality improvement, patient safety, evidence-based practice, and industry standards.
Builds collaborative relationships with physicians, leaders, staff, vendors, and regulatory agencies.
Promotes teamwork, accountability, and a culture of continuous improvement.
Communicates complex information clearly and effectively in written, verbal, and electronic formats.
Demonstrates effective fiscal stewardship and resource management.
Self-motivated, organized, and able to meet goals, priorities, and deadlines.
Working knowledge of Lean, Six Sigma, High Reliability principles, and other performance improvement methodologies.
Champions a culture of learning, innovation, patient-centered care, and operational excellence.
Ability to apply information management principles including planning, aggregating and comparing data through a knowledge base with a focus on improving organizational performance utilizing the process of collaboration and process thinking.
Works in typical acute health care setting with adults, neonates, pediatric, adolescent, and geriatric patients with a moderate to significant amount of walking, sitting, and writing required.
Consists of a significant amount of stress in meeting deadlines and dealing with day-to-day events in the management of the departments.
Need for flexibility and adaptability to change.
Travel to outside agency locations and a flexible schedule are required.
The job requires exposure to Visual Display Terminal (VDT) and continuous repetitive motion of upper extremities.
Requires full range of body motion including possible handling and lifting of patients, manual finger dexterity and eye-hand coordination.
Occasional lifting and carrying of items up to 50 pounds.
Required corrected vision and hearing to normal range.

Nice To Haves

Master’s degree from an accredited college or university in Nursing, Public health, Healthcare administrations, Systems/Industrial engineering or other quality related field preferred.
eNLC RN license if a registered nurse.
One year of director experience highly desirable.
Certified Professional in Health Care Quality (CPHQ) or related certification required within two years.

Responsibilities

Develops, implements, evaluates, and continually improves systems and processes that promote high-quality, safe, patient-centered care.
Ensures compliance with federal, state, and accreditation requirements.
Leads the organization's quality and safety initiatives, including performance improvement, physician peer review, patient safety, credentialing and privileging, regulatory readiness, and Joint Commission accreditation activities.
Leverages data analytics and evidence-based practices to identify opportunities for improvement, establish performance measures, monitor outcomes, and drive sustainable improvements in clinical quality, operational effectiveness, and patient safety.
Fosters a culture of accountability, continuous improvement, and high reliability.
Provides leadership for organizational survey readiness, mandatory reporting requirements, and regulatory programs.
Ensures alignment with strategic goals and industry best practices.
Oversees the day-to-day operations, staffing, fiscal management, and performance of the Quality and Medical Staff Services departments.
Chairs the Patient Safety Committee and champions continuous service readiness.
Promotes organizational excellence through proactive risk identification, performance improvement methodologies, and interdisciplinary collaboration focused on achieving exceptional patient outcomes.