Quality and Patient Safety Specialist

Nexus Health Systems Ltd•San Antonio, TX

12h

About The Position

The Quality and Patient Safety Specialist supports the design, implementation, and continuous evaluation of quality improvement and patient safety initiatives. This position functions as a key operational resource for regulatory compliance, accreditation readiness, incident review, and performance improvement, serving a specialized patient population with neurodevelopmental conditions, complex medical and behavioral health comorbidities, and traumatic brain injury. The Specialist collaborates with interdisciplinary teams to identify risk, reduce harm, and sustain a culture of safety aligned with Nexus Health Systems’ mission and applicable federal, state, and accreditation standards.

Requirements

Associate's degree in healthcare administration, nursing, public health, health sciences, or a closely related field required.
Minimum of two (2) years of experience in healthcare quality, patient safety, regulatory compliance, or a closely related field required.
Proficiency in data collection, analysis, and reporting with the ability to translate findings into actionable recommendations.
Working knowledge of healthcare regulatory and accreditation standards applicable to specialty and behavioral health settings.
Stonge knowledge of quality improvement methodologies.
Ability to conduct or support structured quality and safety reviews including RCA and FMEA.
Demonstrated ability to manage multiple projects and priorities collaborate across interdisciplinary teams.
Proficiency in Microsoft Office Suite; experience with quality management or incident reporting platforms preferred.
Strong written and verbal communication skills with the ability to present findings to multidisciplinary audiences.
Demonstrated ability to manage multiple priorities with attention to detail and consistent follow-through.
BLS (Basic Life Support) from American Heart Association/American Red Cross required, must be valid for a minimum of 6 months from date of hire
De-escalation training within 30 days after hire.

Nice To Haves

Bachelor’s and Master's degree in a relevant field preferred.
Experience in a specialty behavioral health, neurodevelopmental, rehabilitation, or long-term acute care setting preferred.
Experience with accreditation preparation and survey response (DNV, CARF, TJC, or CMS) preferred.
Experience with audits and tracers, incident reporting systems, performance improvement initiatives.
Certified Professional in Patient Safety (CPPS), Certified Professional in Healthcare Quality (CPHQ) or process improvement certification preferred.

Responsibilities

Consistently supports and communicates the Mission, Vision, and Values of Nexus Health Systems
Upholds the Standards of conduct and corporate compliance
Demonstrates honest behavior in all matters. To the best of the employee’s knowledge and understanding, complies with all Federal and State laws and regulations.
Maintains the privacy and security of all confidential and protected health information. Uses and discloses only that information which is necessary to perform the function of the job.
Adheres to all Nexus Health Systems policies on Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI)
Collaborates effectively with colleagues and other departments to ensure seamless service delivery.
Serves as a visible and accessible resource to clinical and operational staff regarding quality, safety, and compliance expectations.
Facilitates interdisciplinary communication related to patient safety events, near-misses, and performance improvement initiatives to support organizational learning and accountability.
Supports the Director of Quality in the design, implementation, and sustainment of a comprehensive Quality Management Program aligned with organizational mission, programs provided, and persons served.
Collaborates with interdisciplinary teams (clinical, behavioral, education, operations) to ensure safe, coordinated, and patient-centered service delivery across the continuum.
Participates in safety rounds, tracers, and environmental assessments to proactively identify system-level risks in the environment (e.g., ligature risk, elopement risk, behavioral escalation environments), consistent with industry patient safety practices.
Promotes a culture of safety, transparency, and just culture principles through daily interactions and committee participation.
Supports the development, implementation, and ongoing monitoring of evidence-based quality improvement initiatives aligned with organizational strategic goals and accreditation requirements.
Conducts data collection, analysis, and reporting for quality indicators, patient safety metrics, and regulatory compliance measures; prepares accurate and timely reports for leadership review.
Assists in the preparation, coordination, and follow-up of internal and external surveys, audits, and accreditation activities (DNV, TJC, CARF, CMS, Texas DSHS, as applicable to the facility).
Participates in root cause analyses (RCAs), failure mode and effects analyses (FMEAs), and other structured safety event reviews, ensuring documentation is accurate, complete, and submitted within required timeframes.
Maintains accurate records and documentation for all quality and patient safety activities in compliance with applicable regulatory, accreditation, and organizational requirements.
Supports the development, review, and revision of policies, procedures, and clinical guidelines to ensure alignment with current evidence-based practice and regulatory standards.
Applies process improvement principles to streamline workflows, reduce waste, and improve compliance reliability.
Monitors and evaluates quality and safety metrics (KPIs), ensuring data integrity, trend analysis, and actionable insights for leadership.
Supports development of standardized audit tools, scorecards, and dashboards to drive consistent measurement of care quality.
Contributes to building a high-reliability organization (HRO) culture through data-driven decision-making and continuous improvement.
Champions patient-centered care and safety for a specialized population with neurodevelopmental conditions, complex behavioral health comorbidities, and traumatic brain injury, applying sensitivity to the unique communication, behavioral, and clinical needs of this population.
Supports processes that protect patients’ rights, dignity, and individualized care in compliance with applicable CMS Conditions of Participation, accreditation standards, and organizational policy.
Advocates for the integration of patient and family feedback into quality improvement planning and safety initiatives.
Collaborates with clinical, behavioral health, and interdisciplinary teams to identify and address safety risks specific to patients with complex neurodevelopmental and behavioral profiles.
Promote patient-centered, trauma-informed, and developmentally appropriate care environments for individuals with neurodevelopmental and behavioral health conditions.
Ensure systems are in place to monitor and respond to grievances, complaints, and patient rights concerns.
Partners with stakeholders to incorporate feedback from people served and families into quality improvement initiatives
Identifies gaps impacting communication, dignity, and safety, especially for populations with cognitive or behavioral complexity.
Ensures all activities adhere to healthcare regulations and organizational policies.
Participates in quality improvement initiatives to enhance service delivery.
Promotes a culture of patient safety which results in the identification and reduction of unsafe practices.
Monitors compliance with applicable federal, state, and accreditation standards including CMS Conditions of Participation, DNV, CARF, Texas DSHS, and the Texas Health and Safety Code.
Ensures organizational alignment with regulatory and accreditation standards, including documentation control, evidence tracking, and reporting compliance.
Prepares and presents quality and patient safety reports to leadership, committees, and regulatory bodies.
Supports event reporting, trending, and follow-up processes consistent with organizational policy and applicable regulatory requirements, including mandatory reporting obligations.
Maintains survey readiness through policy and procedure management, mock surveys, regulatory gap assessments, and corrective action plan tracking.
Tracks corrective action plans (CAPs) and monitors implementation timelines to ensure timely closure and sustained compliance.
Conducts internal audits, tracers, and documentation reviews to evaluate compliance with facility policies, state and federal regulatory standards.
Assists in root cause analysis, proactive risk identification, and incident reporting system management and trending
Completes annual education requirements.
Maintains competency, as evidenced by completion of competency validation requirements.
Maintains competency and knowledge of current standards of practice, trends, and developments.
Participates in relevant workshops, seminars, and continuing education courses to stay current with industry trends, healthcare regulations, and best practices.
Pursues professional development relevant to healthcare quality, patient safety, and regulatory compliance.
Maintains current knowledge of healthcare quality, patient safety, and regulatory standards, including updates from accrediting bodies and state/federal agencies.
Participates in ongoing education related to but not limited to patient safety science, human factors, and behavioral health safety practices.
Supports development and delivery of staff education and training programs on quality and safety topics.
Promotes stewardship of hospital resources while ensuring quality patient care.
Supports cost-effective quality initiatives by identifying waste and inefficiencies and reducing adverse events and associated costs.
Assists in evaluating the financial impact of quality improvement and patient safety initiatives.
Promotes efficient use of resources while maintaining compliance and safety outcomes.
Contributes to data reporting for quality of care and cost-containment strategies.
Performs other duties as assigned.