Director Quality, Patient Safety, and Risk

Texas Health Resources•Allen, TX

1d•Onsite

About The Position

The Director of Quality, Patient Safety and Risk Management will serve as a resource for Texas Health Allen Hospital by offering value-added knowledge and expertise in improving outcomes and providing safe, timely, cost-effective, person-centered care. This position is responsible for sustaining a culture of high reliability, ongoing process improvement and continuous regulatory readiness to ensure the safety of our stakeholders.

Requirements

Bachelor's Degree Clinical/Healthcare Administration Required
3 Years Clinical or operational in a hospital setting Required
3 Years Progressive operational/program management experience Required
CPHQ - Certified Professional in Healthcare Quality with in 2 Years of hire Required
Other If clinical, licensure as required by the State of Texas for clinical discipline Upon Hire Required
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).
Communication skills that demonstrate the ability to develop consensus among the executive leadership team, physicians, and staff.
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.

Nice To Haves

Master's Degree Clinical/Healthcare Administration Preferred

Responsibilities

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.
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.
Conducts evaluations using authoritative interpretive resources to provide an expert analysis and synthesis of the intent, applicability and value of regulations (federal, state, local) and accreditation standards.
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.
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.
Promotes the use of Process and Performance Improvement methods and science throughout the hospital.
Provides education and guidance on the purpose, use and value of quality improvement tools.
Participates in the development of population health improvement models and strategy.
Advises leadership on the impact of evolving payment models and their associated quality metrics for strategic planning and development priorities.
Integrates population health improvement initiatives and metrics into the hospital quality program.
Leads prioritization activities to identify target populations for improvement of care delivery.
Leverages electronic systems to input, analyze, extract, and manage data to support and drive data integrity, streamline process, innovate practices, and achieve positive outcomes.
Develops hospital reports and scorecards incorporating clinical and business metrics tailored to strategic or operational goals.
Promotes a safety culture and infrastructure that aligns with Texas Health’s strategic objectives and meets regulatory/accreditation standards.
Identifies opportunities for improvement and continuously looks for ways to improve processes and reduce harm using the principles of High Reliability.
Conducts and develops comprehensive risk assessments, prioritizes potential risks, and recommends evidence-based strategies for risk reduction.
Prioritizes high risk findings to escalate opportunities for improvement for system leadership awareness and support of risk mitigation strategies.
Provides oversight of the annual assessment and development of the Texas Health Quality Assurance Performance Improvement (QAPI) plan.
Develops and oversees processes for managing professional practice evaluation information across its life cycle, from capture to archive and/or destruction.
Incorporates findings from identified trends across ongoing professional practice evaluation and peer review into performance improvement activities across the organization.
Synthesizes requirements from multiple regulatory and/or payer agencies and communicate organizational impact across various programs.
Pursues/achieves/maintains required applicable certification and licensure.
Pursues professional growth and development of required knowledge and skills.
Participates in a Quality/Regulatory professional organization.
Utilizes the principles of influence, leadership, and change management to advance program goals and ensure changes are vetted by all stakeholder groups.
Utilizes skills in communication, relationship-building, and facilitation to ensure that all stakeholders feel accountable for performance improvement, continuous regulatory compliance and patient safety.
Contributes to the development of other stakeholders through education and mentorship.