Director Quality, Patient Safety, and Risk

Job Qualifications

Regulatory Accreditation, Certification, and Compliance 
1. Responsible for regulatory compliance, accreditation, and continuous survey readiness. Oversees an effective continuous readiness program, including but not limited to, mock surveys, regulatory/accreditation tracers and inter-rater reliability processes.
2. Works in collaboration with hospital leadership to ensure that all required regulatory/certification submissions and follow-up, including the annual mock survey, Evidence of Standards Compliance (ESC), response to TJC, CMS or other regulatory agencies complaint investigations, Measures of Success (MOS) and action plans are appropriate and completed in a timely and thorough manner. 
3. Conducts evaluations using authoritative interpretive resources in order to provide an expert analysis and synthesis of the intent, applicability and value of regulations (federal, state, local) and accreditation standards. 
4. Responsible for coordinating, developing, reviewing, and evaluating policy and guideline documents (policies, forms, protocols, order sets, consents, etc.) for regulatory compliance with consideration and research of evidence-based practice and current best practices.
Performance & Process Improvement
1. Uses Process and Performance Improvement methodology to assess performance, sets achievable goals, uses data to initiate changes, and develops measures that will ensure sustainability of improvements.
2. Promotes the use of Process and Performance Improvement methods and science throughout the hospital.
3. Provides education and guidance on the purpose, use and value of quality improvement tools.

Human Resources – Develop and implement strategy to create and maintain a positive employee relations environment for departmental employees – Recruit, orient and retain excellent staff – Supervise departmental staff, developing standards of performance, evaluating performance and initiating or recommending personnel actions – Mentor job-related growth of staff. 

Population Health & Care Transitions
1. Participate in the development of population health improvement models and strategy.
2. Advise leadership on the impact of evolving payment models and their associated quality metrics for strategic planning and development priorities.
3. Integrate population health improvement initiatives and metrics into the hospital quality program.
4. Lead prioritization activities to identify target populations for improvement of care delivery.
Health Data & Analytics
1. Leverages electronic systems to input, analyze, extract, and manage data to support and drive data integrity, streamline process, innovate practices, and achieve positive outcomes.
2. Develops hospital reports and scorecards incorporating clinical and business metrics tailored to strategic or operational goals. 

Patient Safety
1. Promote a safety culture and infrastructure that aligns with Texas Health’s strategic objectives and meets regulatory/accreditation standards.
2. Identifies opportunities for improvement and continuously looks for ways to improve processes and reduce harm using the principles of High Reliability.
3. Conducts and develops comprehensive risk assessments, prioritizes potential risks, and recommends evidence-based strategies for risk reduction.
4. Prioritize high risk findings in order to escalate opportunities for improvement for system leadership awareness and support of risk mitigation strategies.
Quality Review & Accountability
1. Provides oversight of the annual assessment and development of the Texas Health Kaufman Quality Assurance Performance Improvement (QAPI) plan.
2. Develop and oversee processes for managing professional practice evaluation information across its life cycle, from capture to archive and/or destruction.
3. Incorporate findings from identified trends across ongoing professional practice evaluation and peer review into performance improvement activities across the organization.
4. Synthesize requirements from multiple regulatory and/or payer agencies and communicate organizational impact across various programs.

Professional Engagement
1. Pursues/achieves/maintains required applicable certification and licensure.
2. Pursues professional growth and development of required knowledge and skills.
3. Participates in a Quality/Regulatory professional organization.

Leadership & Integration
1. Utilizes the principles of influence, leadership, and change management to advance program goals and ensure changes are vetted by all stakeholder groups.
2. Utilizes skills in communication, relationship-building, and facilitation to ensure that all stakeholders feel accountable for performance improvement, continuous regulatory compliance and patient safety
3. Contributes to the development of other stakeholders through education and mentorship.
  
Education
Bachelor’s Degree Clinical or Healthcare Administration Required
Master’s Degree Clinical or Healthcare Administration Preferred

Experience
7 Years Clinical or operational experience in a hospital Required
 and
5 Years Progressive operational/program management experience Required
3 Years Functioning at Integrated Health System level Preferred
High reliability organization (HRO) experience Preferred
Leadership experience a Plus

Licenses and Certifications
RN – Registered Nurse Upon Hire Required
 Or
CPHQ – Certified Professional in Healthcare Quality Upon Hire Required
 Or
CPHRM – Certified Professional in Healthcare Risk Management Upon Hire Required

Skills
Knowledge of accreditation and industry standards: Life Safety Code (LSC), The Joint Commission (TJC), Center for Medicare and Medicaid Services (CMS), National Quality Foundation (NQF), Institute for Healthcare Improvement (IHI), Texas Department of State Health Services (TDSHS), Hospital Incident Command Systems (HICS), and Federal Emergency Management Agency (FEMA).
Must exhibit a comprehensive understanding of performance improvement methodologies, theory and practice.
Demonstrated skills in strategic planning, implementing action plans, and evaluating and enhancing programs.
Ability to lead transformational change resulting in improved patient safety, high reliability and quality of care.

Why Texas Health? 

At Texas Health Resources, our mission is “to improve the health of the people in the communities we serve”.

As part of the Texas Health family and its 28,000+ employees, we’re one of the largest employers in the Dallas Fort Worth area. Our career growth and professional development opportunities are top-notch and our benefits are equally outstanding. Come be a part of our exceptional team as we improve the health of the people in our communities every day. You belong here.

Learn more about our culture, benefits, and recent awards. 

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