HCA, Hospital Corporation of America Division Director of Quality in Tallahassee, Florida

This position is located in our North Florida Division office in Tallahassee, FL. Responsible for managing and coordinating quality and patient safety initiatives, Infection Control, and Medical Staff Services in order to support the division strategic plan and goals, and meet HCA quality objectives and standards. In this regard, s/he will have responsibility for facilitating and coordinating activities in:

  • Clinical excellence and patient safety

  • Process improvement and outcomes management

  • Regulatory readiness to include CMS Conditions of Participation, Agency for Healthcare Administration, and The Joint Commission

  • Knowledge related to Disease Specific Certification.

  • Core Measures

  • Infection Control

  • Medical Staff Office Credentialing Services

  • Project Management to include annual Patient Safety Program.
    Coordinates his/her work closely with the Division VP Quality and the Division Chief Medical Officer. Responsible for ensuring facility compliance with The Joint Commission, Centers for Medicare and Medicaid Services (CMS) Conditions of Participation, AHCA, Disease Specific Certifications, and other standards, rules and regulations. Position requires occasional travel as well as temporary placement in hospitals without quality leadership.

  • Facilitating the growth of division and hospital knowledge regarding quality, clinical performance and related areas, including the dissemination of “best practices” across the division.

  • Leading division-wide standardization in targeted process improvement initiatives, and evaluating success through pre-established criteria

  • Supporting facility’s response to Serious Patient Adverse Events (SPAE)

  • Leading proactive patient safety activities to create hospitals that are high reliability organizations, as reflected in reduced errors, elimination of unsafe processes, and increased involvement of staff and physicians toward a culture of safety.

  • Contributing to the achievement of business and financial goals through optimal division performance in quality and patient safety.

  • Collaborating with and supporting hospital quality, risk, safety and infection prevention leaders to achieve top ranking in national and state publicly reported data initiatives.

  • Participating in regular analysis of division quality and risk performance data; planning steps for ongoing improvement.

  • Working with Division VP Quality to support data analysis, reporting, and outcomes improvement. Contributing to ongoing enhancement of division quality reporting methods and dashboards.

  • Continuously monitoring and evaluating quality outcomes for patient care across the division, while noting trends, and identifying and prioritizing opportunities to improve.

  • Assisting with ensuring the data is reported to approved third parties, such as Leapfrog, VON, NHSN, NCDR & STS databases, etc.

  • Assisting facilities in building a proactive quality department by implementing tracer teams responsible for identifying processes that are non-compliant with Joint Commission, COP, Title 22 and other regulatory requirements.

  • Facilitating and/or leading clinical process improvement teams as needed to achieve quality improvement goals.

  • Serving as a regulatory resource regarding state and federal regulations and standards, including but not limited to CMS, Joint Commission, CDC, Professional Practice Acts, and Agency for Health Care Administration.

  • Staying current with NQF, AHRQ, Leapfrog, IHI and other quality performance initiatives.

  • Support of the Medical Staff Office personnel through familiarity with the Credentialing Process, hospital Bylaws, and operational understanding of the Centralized Processing process.

  • Support of Patient Safety Directors through working knowledge of the Serious Event Analysis process. This also includes preparation of PSD staff for presentation to regulatory agencies.

  • Promoting a culture that is positive, values individual strengths, takes risks, and is committed to optimal patient care, and compliance with standards.

  • Attending HCA-mandated training and meeting all ethics and compliance standards and requirements. Developing and implementing division level projects as directed by Division CMO and Division VPQ.

  • Requires ability to function in Quality Leadership role in an interim capacity in hospitals throughout the division.

    Education:

  • Bachelor’s degree in a clinically related field, preferably Registered Nurse is required.

  • Master’s degree MHA, MBA, MSN or related field is preferred.

  • Five (5 ) years of experience in Leadership in a clinical and quality improvement setting in an Acute Care Hospital is required.

  • Management experience is required.

  • Previous experience within a multi-facility environment is preferred.

    License, Certification

  • Clinical licensure, preferably RN is required.

  • Certified Professional in Healthcare Quality (CPHQ) and/or Certified Professional in Patient Safety (CPPS) is required

Job: *Directors & Managers

Title: Division Director of Quality

Location: Florida-Tallahassee-North Florida Shared Services

Requisition ID: 25086-9295