Director Quality, Patient Safety, and Risk

Key Responsibilities 

OPERATIONS: ACCREDITATION/CLINICAL CERTIFICATION – Oversight and facilitation of accreditation activities to include but not limited to: TJC, Chest Pain & Stroke certifications Bariatric certification, etc. 

OPERATIONS: PI/PATIENT SAFETY – Direct and support processes and coordinate tactics that advance patient safety and performance improvement. Track, trend and monitor performance improvement outcomes and risk events. Work with other departments on hospital and system initiatives and support evidence-based best practices. Ensure annual completion of FMEA for the acute care and Seay Behavioral Health Center. Direct clinical outcomes program. 

OPERATIONS: PEER REVIEW – Oversee and facilitate Medical Staff Peer Review, including Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE). Assist peer review physicians and division chiefs in preparing and presenting case reviews and completing follow-up activities based on peer review findings. 

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. 

LEADERSHIP: Plan and execute in collaboration with Chief Medical Officer, Chief Nurse Executive and Texas Health leadership the implementation of a comprehensive quality and safety management process. Develop and maintain KPI quality dashboard. Direct the preparation and maintenance of department reports and tracking of data for quality and safety initiatives, including preparation of reports for committees and top management as required. Monitor and supervise hospital compliance with The Joint Commission (TJC) and governmental agencies, standards and requirements, acting as liaison during site reviews. Participate in and represent THP in system-wide quality/patient safety committees and initiatives. Take initiative and coordinate with other departments to develop action plans for performance improvement and patient safety initiatives and risk reduction. 

OPERATIONS: ASSIST IN INVESTIGATION/RESPONSE TO SENTINEL EVENTS/NEAR MISSES/COMPLAINTS/GRIEVANCES – Conduct initial investigation of events to begin information gathering process. Work with CQO/hospital staff/medical staff regarding management of event and communication with the patient/family. Communicate with the patient/family as necessary. Coordinate and facilitate RCA meetings and development of action plans. Monitor progress and effectiveness of RCA Action Plans. Work with Risk Manager to develop reports and results of action plans for Risk Management/Patient Safety Committee and Quality Integration Committee. Manage complaint/grievance process. 

FISCAL RESPONSIBILITY: Assist in development of capital and operational budget and monitor compliance of same. Consider clinical, quality and operational outcomes and financial implications when making recommendation for changes in practices. 
 
Education
Bachelor’s Degree Clinical or Healthcare Administration Required
 And
Master’s Degree Preferred

Experience
7 Years clinical or in a hospital setting Required
 and
5 Years progressive operational/program management experience Required
Managerial Experience Strongly Preferred
Quality Experience Preferred 

Licenses and Certifications
Other Licensure as required by the state of Texas for applicable clinical discipline Upon Hire Required
 And
CPHQ – Certified Professional in Healthcare Quality with in 2 Years of hire Required

Skills
Excellent verbal and written communication, negotiation and collaboration skills; ability to collect, analyze and organize data; team facilitation skills; knowledge of regulatory and accreditation requirements; ability to educate and motivate; able to use Microsoft Office applications

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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