Nurse Director of Performance Improvement and Quality

  • Company: Hospital Corporation of America
  • Location: Low Moor, Virginia
  • Posted: November 10, 2017
  • Reference ID: 02962-18648
LewisGale Hospital Alleghany:

We specialize in cardiac rehab, orthopedics, physical therapy, surgical services and mental health and behavioral health services-particularly the Senior Transitions Program available at our stand-alone geriatric psychiatry unit in our beautiful Blue Ridge mountain setting. In addition, our Women's Center achieves the highest rating possible under the FDA Mammography Quality Standards Act.

Within LewisGale Regional Health System, including LewisGale Hospital Alleghany, you'll find hospitals with accredited Chest Pain Centers. This designation from The Society of Cardiovascular Patient Care recognizes our exceptional efforts to create better outcomes for potential heart attack patients. LewisGale Hospital Alleghany was Virginia's first rural hospital to reach this important milestone.


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 and ensuring availability and assessment of comparative quality data as available for credentialing activities.

2 Provides direction to the hospital for the development of a proactive, hospital-wide risk management and patient safety program, achieve annual goals and reduce associated cost.

3 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.

4 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.

5 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.

6 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.
Required - Five years of current experience in nursing in which leadership and management
abilities have been demonstrated.
Preferred - Three years management experience with quality experience.

Required - Current Virginia licensure by the State Board of Nursing as a Registered Professional Nurse.

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