Director Quality Patient Safety and Risk-Forney

Texas Health Resources•Forney, TX

2d•Onsite

About The Position

The Director of Quality, Patient Safety and Risk Management serves as a resource for Texas Health Forney, offering expertise to improve outcomes and provide 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; leads performance and process improvement; and manages departmental staffing and development. The role integrates population health initiatives and metrics into the hospital quality program, uses health data and analytics to support performance, promotes patient safety and risk reduction, and oversees quality review and accountability activities. The director also advances program goals through leadership, change management, communication, education, and mentorship.

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.
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 resulting in improved patient safety, high reliability, and quality of care.

Nice To Haves

Master’s degree in Clinical or Healthcare Administration.
Three years of experience functioning at an Integrated Health System level 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 on regulatory and certification submissions and follow-up, including Evidence of Standards Compliance, responses to TJC, CMS, or other agencies, complaint investigations, Measures of Success, and action plans.
Evaluate regulations and accreditation standards using authoritative interpretive resources and provide expert analysis of their intent, applicability, and value.
Coordinate, develop, review, and evaluate policies and other guideline documents for regulatory compliance and alignment with evidence-based practices.
Use process and performance improvement methods to assess performance, set goals, use data to initiate changes, and develop measures to sustain improvements.
Promote process and performance improvement methods throughout the hospital and provide education and guidance on quality improvement tools.
Develop and implement strategies to maintain a positive employee relations environment; recruit, orient, retain, supervise, evaluate, and mentor departmental staff.
Participate in developing population health improvement models and strategy, and advise leadership on evolving payment models and associated quality metrics.
Integrate population health initiatives and metrics into the hospital quality program and lead prioritization of target populations for care delivery improvement.
Use electronic systems to input, analyze, extract, and manage data, supporting data integrity, efficient processes, innovation, and positive outcomes.
Develop hospital reports and scorecards that incorporate clinical and business metrics tailored to strategic or operational goals.
Promote a safety culture 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.
Prioritize high-risk findings and escalate improvement opportunities for system leadership awareness and risk mitigation support.
Oversee the annual assessment and development of the Texas Health Kaufman Quality Assurance Performance Improvement plan.
Develop and oversee processes for managing professional practice evaluation information through its lifecycle, and incorporate trends from professional practice evaluation and peer review into performance improvement.
Synthesize requirements from multiple regulatory and payer agencies and communicate organizational impacts across programs.
Maintain applicable certifications and licensure, pursue professional development, and participate in a quality or regulatory professional organization.
Use influence, leadership, change management, communication, relationship-building, and facilitation to advance program goals and stakeholder accountability.
Educate and mentor stakeholders to support their development.