Quality Improvement and Survey Readiness Manager Monday - Friday Full Time - 8am - 4:30pm

About us: For the past 85 years, Stephens County Hospital has been a trusted name in the community, striving for excellence and delivering professional and compassionate care. Our dedicated staff of approximately 475 employees has a heart for healthcare and realizes how precious the gift of good health can be.

Stephens County Hospital is a 96-bed acute care hospital located in Toccoa, Georgia. We are nestled in the beautiful foothills of Northeast Georgia where our family-oriented community offers many cultural and civic opportunities as well as numerous outdoor activities.

Stephens County Hospital is a member of the Georgia Hospital Association, American Hospital Association and Georgia Alliance of Community Hospitals. Stephens County Hospital is fully accredited by the Joint Commission, the nation's premier healthcare monitoring agency.

Quality Improvement and Survey Readiness Manager Monday - Full Time - Friday 8am - 4:30pm

The Quality Improvement Manager position is responsible for facilitating system-wide Quality Improvement Program, overseeing Customer Satisfaction Program, Mandatory reporting of quality indicators to CMS and State, Coordination of medical staff peer review and quality reports, coordination of compliance with accreditation agency and clinical regulatory standards. Offers support to the Risk/Compliance Officer in the form of assisting with investigations of potential compliance issues, record keeping as needed, and helping to maintain regulatory conformity.

Education:

4 year / Bachelor's Degree in in relevant field (Required)

Master's Degree in in relevant field (Preferred)

Registered Nurse is required

BSN is the minimum education requirement with MSN preferred, highly desired

Experience:

Preferred Certifications/Licensures: Certified Professionals in Healthcare Quality (CPHQ)

Lean Six Sigma knowledge/training (preferred)

Registered Nurse is required

Duties and Responsibilities:

Coordination of prioritization, integration, implementation and evaluation of annual quality plan for the organization.

Responsible for coordinating all regulatory and accreditation standards compliance.

Coordinate all purchases of related databases for QI in collaboration with IS.

Knowledgeable of CQI tools and techniques and able to impart that knowledge to others in a manner to obtain compliance.

Responsible for organization wide QI reporting to Medical Executive Committee and Department Heads.

Designs system to facilitate collection, trending and analysis of data.

Serves as internal consultant for those needing assistance with QI initiatives.

Coordination of QI education. Provides educational programs to hospital employees, medical staff, and the community regarding topics of QI.

Assists with Peer Review procedures in conjunction with medical staff.

Knowledgeable of TJC standards. Able to interpret standards into policies, procedures, or formation of processes to comply with stated standards.

Assists as needed for continuous TJC compliance.

Knowledge, Skills, and Abilities

• Strong organizational and interpersonal skills
• Ability to determine appropriate course of action in more complex situation
• Ability to work independently, exercise creativity, and maintain a positive attitude
• Ability to manage multiple and simultaneous responsibilities and to prioritize scheduling of work
• Ability to maintain confidentiality of all medical, financial, and legal information
• Ability to complete work assignments accurately and in a timely manner
• Ability to communicate effectively, with excellent verbal and written communication skills
• Knowledgeable and skilled with Microsoft Office to include Word, Excel, Power Point, etc.

Non-Essential Functions

• Perform other duties as assigned or requested.

Professional Requirements

• Adhere to dress code, appearance is neat and clean.
• Complete annual education requirements.
• Maintain patient confidentiality at all times.
• Report to work on time and as scheduled.
• Wear identification while on duty.
• Maintain regulatory requirements, including all state, federal and local regulations.
• Represent the organization in a positive and professional manner at all times.
• Comply with all organizational policies and standards regarding ethical business practices.
• Participate in performance improvement and continuous quality improvement activities.
• Attend regular staff meetings and in-services as needed.

Physical Requirements and Environmental Conditions

* Have near normal hearing - able to hear alarms/telephone/normal speaking voice/ webinars

* Have near normal vision - clarity of vision (both near and far) either corrected on non-corrected, ability to distinguish colors

* Have good manual dexterity and eye-hand-foot coordination

* Standing - continuously within the shift (67-100%)

* Walking - continuously within the shift (67-100%)

* Climbing - occasionally within the shift (1-33%)

* Bending/stooping - frequently within the shift (34-66%)

*Twist at the waist - occasionally with the shift (1-33%)

*Pushing/pulling - frequently within the shift (34-66%)

* Lift/carry - 20lbs with assistance - occasionally within the shift (1-33%)

* Reaching above the shoulders - frequently within the shift (34-67%)

* Lift/carry - 50lbs with assistance - occasionally within the shift (1-33%).

Stephens County Hospital is an equal opportunity employer. All applicants will receive consideration for employment without regard to race, color, religion, sex, age, pregnancy, marital status, national origin, citizenship status, disability, military status, sexual orientation, genetic predisposition, carrier status or any other legally protected status.