Executive Director - Quality and Accreditation

Northeast Georgia Health System, Inc
Gainesville, Georgia
Apr 18, 2024
Apr 30, 2024
Position Type
Full Time
Work Mode
Employment Type
Job Category:
Executive Leadership
Work Shift/Schedule:
8 Hr Morning - Afternoon

Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

About the Role:

Job Summary

The Executive Director of Quality and Accreditation is responsible for overseeing the patient safety and quality programs for Northeast Georgia Medical Center (NGMC) System Acute Care Services. This includes Quality Improvement, Data Analytics and Reporting, Patient Safety, Accreditation/Regulatory Compliance, Policy/Document Control, and Infection Prevention/Control. He/She shall be responsible, in conjunction with senior leadership, for ensuring that the requirements of the Quality Management System (QMS) for NGHS is determined, implemented, and maintained. This position will also work collaboratively with NGHS entity leadership to align the quality and safety programs of all acute care, post-acute care, and ambulatory entities of NGHS and assure support of system strategies and consistency throughout. This includes identifying and proposing potential safety and quality projects that are aligned with organizational strategic objectives.

Minimum Job Qualifications

  • Licensure or other certifications:
  • Educational Requirements: Bachelors Degree
  • Minimum Experience: Minimum 5-7 years experience in healthcare quality and accreditation, and 5 years prior healthcare related leadership experience required
  • Other:

Preferred Job Qualifications

  • Preferred Licensure or other certifications:
  • Preferred Educational Requirements: Master Healthcare Administration, Business Administration or Organization Leadership strongly preferred.
  • Preferred Experience:
  • Other:

Job Specific and Unique Knowledge, Skills and Abilities

  • Strong written and verbal communication skills
  • Strong organizational skills
  • Excellent interpersonal and facilitation skills
  • Thorough knowledge of improvement strategies and methods including RCAs and High Reliability processes.
  • Strong Data Analytics capabilities

Essential Tasks and Responsibilities

  • Oversees and supports the patient safety and quality infrastructure for NGMC System Acute Care Services, including data governance.
  • Aligns the patient safety, quality, accreditation, and infection prevention and control programs for System Acute Services with that of all NGHS entities.
  • Uses information from a variety of sources to identify opportunities for improvement.
  • Tracks performance relative to national benchmarks providing feedback/data to leadership and guidance toward effective performance improvement interventions.
  • Develops and coordinates system level quality oversight structure/committee.
  • Promotes and supports professional growth and development of staff.
  • Provides outstanding service to all customers, fosters teamwork, and practices fiscal responsibility.
  • Hires, disciplines, trains and develops, and conduct performance evaluations for assigned staff.
  • Develops and monitors the payroll, non-payroll, capital and operating budgets for assigned areas.
  • Develops, initiates, maintains, and revises policies for the general operation of the Patient Safety and Accreditation/Quality programs.
  • Collaborates with Patient Safety and Quality leaders within NGHS entities to increase visibility and sharing of metrics and initiatives.

Physical Demands

  • Weight Lifted: Up to 20 lbs, Occasionally 0-30% of time
  • Weight Carried: Up to lbs, Occasionally 0-30% of time
  • Vision: Moderate, Constantly 66-100% of time
  • Kneeling/Stooping/Bending: Occasionally 0-30% of time
  • Standing/Walking: Occasionally 0-30% of time
  • Pushing/Pulling: Occasionally 0-30% of time
  • Intensity of Work: Frequently 31-65% of time
  • Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding

Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals.

NGHS: Opportunities start here.

Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.