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Job Code: 3037
Department: Performance Improvement/Accred
Schedule: Full-time
Shift: Day shift
Contact Information:
  • Contact: Allison Sizemore
Job Details:
  • Masters degree is required

    Responsible for planning, budgeting, organizing, leading, and evaluating the overall operation of the performance improvement program and ensuring Joint Commission Accreditation readiness as it pertains to Performance Improvement and the Medical Staff functions.  Oversees and analyzes the interpretation of historical data, current market trends, and forecasted health care trends in the development of strategic performance improvement goals that support the organization’s mission, vision, and strategic goals.  Directs the integration of performance improvement throughout the health system. Responsible for developing and implementing an integrated approach to improving performance and patient safety across the health system.  Oversees system-wide clinical benchmarking to analyze and measure organizational excellence.  Manages and oversees the medical staff department functions such as committees, performance improvement, and medical staff services.  Oversees the FPPE and OPPE functions.  Evaluates and maintains Joint Commission readiness as it relates to the medical staff standards.  Manages and oversees the Medical Staff’s continuing Education function.  Evaluates and maintains accreditation of the Medical Association of the State of Alabama.



    • Masters Degree in health-related field required;
    • Five (5) years experience at the Manager or Director Level or above in performance improvement in a health-related setting required;
    • Minimum of seven (7) years health care management experience in a hospital setting;
    • In-depth knowledge of current concepts in performance improvement and curriculum development in adult education;
    • Proficient in planning, designing and implementing performance improvement activities;
    • Current knowledge of Joint Commission Hospital Accreditation Standards;
    • Strong written and oral communication and organizational skills;
    • Strong statistical concepts and applications;
    • Knowledge of microcomputers and associate software (Microsoft Excel, Word, PowerPoint and Access) and experience in presentation of statistical data;
    • Possess the ability to establish and maintain effective professional and interpersonal relationships with all levels of the organization, professional organizations and regulatory services.


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