Director Quality, Patient Safety, and RiskAre you looking for a rewarding career with family-friendly hours and top-notch benefits? We’re looking for qualified candidates like you to join our Texas Health family.
Work location: Texas Health Southwest
Core work hours: Monday – Friday; 8:00a-5:00p
At Texas Health Southwest and Texas Health Clearfork we’re one hospital in two locations. We’re a 261-bed, full-service hospital serving southwest Fort Worth and surrounding areas since 1987.We specialize in surgical services, orthopedics, rehab services, imaging services and adult critical care, and we have a 24-hour emergency department. Plus, we are a certified Primary Heart Attack center, certified Primary Stroke center, Level III Trauma, Level III Maternal, Level III Neonatal center, certified Total Hip and Total Knee Replacement facility, and a nationally accredited Breast Center.Texas Health Southwest has received Magnet designations, plus a CMS 5-Star rating, the US News & World report top hospital award, and multiple awards for STEMI/NSTEMI.Position SummaryThe Director of Quality, Patient Safety and Risk Management will serve as a resource for Texas Health Southwest 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.Job DescriptionRegulatory Accreditation & Certification1 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 in order 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.
Performance & Process Improvement
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.
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.Performance & Process Improvement
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.
Population Health & Care Transitions
Participate in the development of population health improvement models and strategy.
Advise leadership on the impact of evolving payment models and their associated quality metrics for strategic planning and development priorities.
Integrate population health improvement initiatives and metrics into the hospital quality program.
Lead prioritization activities to identify target populations for improvement of care delivery.
Health Data & Analytics
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.
Patient Safety / Risk Management
Promote 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.
4.Prioritize high risk findings to escalate opportunities for improvement for system leadership awareness and support of risk mitigation strategies. Review of root cause analysis if serious safety events
Peer Review management and oversee patient grievances.
Quality Review & Accountability
Provides oversight of the annual assessment and development of the Texas Health Southwest Quality Assurance Performance Improvement (QAPI) plan.
Develop and oversee processes for managing professional practice evaluation information across its life cycle, from capture to archive and/or destruction.
Incorporate findings from identified trends across ongoing professional practice evaluation and peer review into performance improvement activities across the organization.
Synthesize requirements from multiple regulatory and/or payer agencies and communicate organizational impact across various programs.
Professional Engagement
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.
Leadership & Integration
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.
EducationBachelor's Degree Clinical/Healthcare Administration RequiredMaster's Degree Clinical/Healthcare Administration PreferredExperience7 Years Clinical or operational experience in a hospital setting Requiredand5 Years Progressive operational/program management experience Required3 Years Functioning at an Integrated Health System levelHigh reliability organization (HRO) experience PreferredLicenses and CertificationsCPHQ - Certified Professional in Healthcare Quality with in 12 Months of hire PreferredOrCPHRM - Certified Professional in Healthcare Risk Management with in 12 Months of hire PreferredSkillsExcellent 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 applicationsWhy 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 (https://jobs.texashealth.org/why-texas-health/) more about our culture, benefits, and recent awards.#LI-TA1Texas Health requires a resume when an application is submitted.Employment opportunities are only reflective of wholly owned Texas Health Resources entities.We are an Equal Opportunity Employer and do not discriminate against any employees or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.