Director Quality Patient Safety and Risk-Forney

Texas Health•Forney, TX

1d•Onsite

About The Position

The Director of Quality, Patient Safety and Risk Management serves as a resource for Texas Health Forney, providing expertise to improve outcomes and deliver safe, timely, cost-effective, person-centered care. The position is responsible for sustaining a culture of high reliability, ongoing process improvement, and continuous regulatory readiness to ensure stakeholder safety. The Director oversees regulatory compliance, accreditation, certification, and continuous survey readiness, working with hospital leadership on regulatory submissions, follow-up, complaint investigations, and action plans. The role evaluates regulations and accreditation standards and coordinates the development and review of policies, guidelines, and related documents for compliance and alignment with evidence-based practice. The role promotes performance and process improvement, supports population health and care transitions, and uses electronic systems and analytics to strengthen data integrity and develop reports and scorecards. It advances patient safety through risk assessments and evidence-based risk reduction, and oversees quality review and accountability activities, including the annual QAPI plan and professional practice evaluation processes. The Director also leads departmental human resources activities, including recruitment, retention, supervision, performance evaluation, and staff development. The position uses leadership, change management, communication, relationship-building, and facilitation to advance program goals and build stakeholder accountability for performance improvement, regulatory compliance, and patient safety. Work location is Texas Health Forney in Forney, Texas. Core work hours are full time, Monday through Friday, 8:00 a.m. to 5:00 p.m.

Requirements

Bachelor’s degree in Clinical or Healthcare Administration.
Seven years of clinical or operational experience in a hospital.
Five years of progressive operational or program management experience.
Three years functioning at an Integrated Health System level.
Upon hire, one of the following is required: Registered Nurse (RN), Certified Professional in Healthcare Quality (CPHQ), or Certified Professional in Healthcare Risk Management (CPHRM).
Knowledge of accreditation and industry standards, including Life Safety Code (LSC), The Joint Commission (TJC), Centers 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).
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 that improves patient safety, high reliability, and quality of care.

Nice To Haves

Master’s degree in Clinical or Healthcare Administration.
Experience in a high reliability organization (HRO).

Responsibilities

Oversee regulatory compliance, accreditation, certification, and continuous survey readiness, including mock surveys, tracers, and inter-rater reliability processes.
Collaborate with hospital leadership to complete required regulatory and certification submissions and follow-up, complaint investigations, Measures of Success, and action plans accurately and on time.
Evaluate federal, state, and local regulations and accreditation standards using authoritative interpretive resources.
Coordinate, develop, review, and evaluate policies, forms, protocols, order sets, consents, and guidelines for regulatory compliance and alignment with evidence-based practice.
Use performance and process improvement methods to assess performance, set goals, apply data to changes, and develop measures to sustain improvements.
Promote process and performance improvement methods throughout the hospital and educate staff on quality improvement tools.
Develop and implement strategies for positive employee relations; recruit, orient, retain, supervise, evaluate, and mentor departmental staff.
Participate in developing population health improvement models and strategy; advise leadership on evolving payment models and quality metrics.
Integrate population health initiatives and metrics into the hospital quality program and lead prioritization of target populations for care improvement.
Use electronic systems to input, analyze, extract, and manage data, supporting data integrity, streamlined processes, innovation, and positive outcomes.
Develop hospital reports and scorecards using clinical and business metrics tailored to strategic or operational goals.
Promote a patient safety culture and infrastructure aligned with Texas Health’s strategic objectives and regulatory and accreditation standards.
Identify opportunities to improve processes and reduce harm using High Reliability principles; conduct risk assessments and recommend evidence-based risk reduction strategies.
Escalate high-risk findings and improvement opportunities to system leadership for awareness and support of mitigation strategies.
Oversee the annual assessment and development of the Texas Health Kaufman QAPI plan.
Develop and oversee processes for managing professional practice evaluation information through its lifecycle.
Use trends in professional practice evaluation and peer review to inform organizational performance improvement activities.
Synthesize requirements from regulatory and payer agencies and communicate their organizational impact.
Maintain applicable certifications and licensure, pursue professional development, and participate in a Quality/Regulatory professional organization.
Use leadership, influence, and change management to advance program goals and ensure changes are vetted by stakeholder groups.
Use communication, relationship-building, and facilitation to promote stakeholder accountability for improvement, compliance, and safety.
Develop stakeholders through education and mentorship.