Director Quality Assurance
Georgetown , Texas
December 17, 2017

1. Implements and manages quality activities throughout the facility including peer review, quality initiatives and other PI activities.
  • Performs annual quality and PI program evaluation and reporting.
  • Develops, revises, and implements quality and PI plan.
  • Serves as a quality resource to all departments, staff, etc.
  • Maintains and coordinates quality and PI report cards, dashboard, and other reporting mechanisms.
  • Serves as member of selected facility and departmental PI committees, teams. Serves as Quality Facilitator/Leader of root cause analysis teams, (RCAs), FMEAs, etc.
  • Analyzes and reports quality and PI indicators to the Quality Management Committee, Administration, and others as indicated.
  • Ensures compliance of corporate, regulatory, and accreditation requirements for quality, performance improvement, and patient safety.
  • Serves as representative to selected Partnership and other quality committees, initiatives, etc.
  • Coordinates quality activities with Quality Manager and other staff.
  • Manages and guides physician peer review activities with the Quality Manager and Chief Medical Officer.
  • Manages Quality Management Committee activities through coordination of agenda, oversees minutes, reports, and other activities of the Committee.
  • Manages patient safety, national, corporate and other quality or patient safety initiatives. Leads and facilitates designated initiatives.
  • Provides education to staff regarding quality and patient safety initiatives; promotes compliance and improvement.

2. Responsible for data analysis, collection and outcomes measures.
  • Analyzes and reports data from clinical outcomes systems such as CHOIS, TMF, Core Measures, THCIC, Q-Net, etc. as required or requested.
  • Recommends action plans based on clinical and other data to Medical Director, Medical Staff, Quality Management Committee, Administration, etc.
  • Manages Core Measure reporting and other outcomes measures as determined by the Medical Staff, Administration, etc..
  • Ensures collection, maintenance, and reporting of data for profiles (medical staff and allied health professionals) in a timely manner to ensure quality data and/or recommendations for physician credentialing and appointment/reappointment activities. Provides profiles to Medical Staff Department for credentialing and quality file purposes, and to the respective practitioner.
  • Maintains quality and PI software and reporting systems to meet internal and external reporting requirements and surveys. Assists with selection and installation of software applications.
3. Manages departmental operations.
  • Ensures appropriate, timely, and professional communications.
  • Develops and reviews department policies and procedures at least annually.
  • Develops, implements and reviews goals, objectives and priorities, ensuring alignment with hospital strategic plans.
  • Organizes departmental activities based on priorities, goals, objectives, and needs as arise.
  • Assigns and adjusts staffing to meet priorities, goals, and objectives of department while ensuring smooth operations.
  • Performs department human resource activities, e.g. staffing, competencies, training and skill checklists; annual and periodic performance evaluations; staff relations, staffing adjustments, etc.
  • Ensures appropriate supplies and equipment are available to perform activities.
  • Prepares budgets, productivity and other operational activities.
  • Develops and implements department performance improvement (PI) plan and submits reports as required.
  • Obtains and implements databases and other computer software to enhance department performance.
  • Creates and analyzes a variety of reports as requested or needed.
  • Develops and implements department policies and procedures.
  • Conducts and records monthly department meetings with staff.
  • Addresses and resolves complaints.
4. Maintains compliance with current regulation/requirements of outside regulatory/accrediting agencies and assures that new requirements are identified on a timely basis and coordinates hospital compliance.
  • Demonstrates understanding of Process Improvement. Promotes the systematic assessment and improvement of performance. Continuously assesses and improves the performance of care and services provided by using information available from customers (i.e., patients, staff, physicians, and employees), to improve outcomes.

  • Employee's conduct must reflect the Company's values and a commitment to the Code of Conduct ethics and compliance program.

  • Adheres and upholds all service behaviors as listed in the I CARE value commitment and other departmental initiatives.

  • Completes other duties as needed.
  • Maintains confidentiality.
  • Performs other duties as assigned.
  • Complies with all hospital policies and procedures, safety requirements, and
  • Emergency preparedness requirements.

  • Employee's conduct must reflect the Company's values and a commitment to the Code of Conduct ethics and compliance program.


Must be able to demonstrate understanding of HCA's and St. David's Georgetown Hospital "Patients First" safety initiative by strict compliance to all safety protocols and procedures.

Understanding of quality principles, theories and tools. Data analysis and statistical background required. Ability to perform computerized analyses and use data management, word processing, and presentation software as required. Understanding of healthcare environment and strong project management skills are necessary for this position. Understanding of clinical information, organizational behavior and group dynamics helpful. Ability to interact effectively with a variety of professions and persons. Comfortable and skilled at working with physicians, health care providers, and other stakeholders in the organization. Effective written and verbal communication skills. Ability to perform detailed, concentrated work with limited supervision. Ability to identify issue and initiate improvements.


Required: 2 years leadership experience in healthcare
Preferred: 5 years leadership experience in healthcare. RN or other clinical licensure as applicable. Master's Degree in Nursing, Quality Management, Healthcare Administration or a clinical field. Ten years experience in healthcare or five years' experience in Healthcare Quality.


Preferred: CPHQ (Certified Professional in Healthcare Quality or CPHRM (Certified
Professional in Risk Management), CPPS (Certified Professional in Patient Safety)
RN or other clinical licensure as applicable.

A little about us:
HCA is the nation’s leading private provider of healthcare services. Comprised of locally managed facilities which include 230,000 employees at over 160 hospitals, over 120 surgery centers and 100 urgent care facilities in 20 states and the United Kingdom

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