JOB SUMMARY: This position provides leadership and is responsible for the region-wide implementation of the Quality and Patient Safety Program that aligns with the strategic initiatives of the Baylor Scott & White Health System. The Director facilitates all aspects of quality assurance, quality control, and quality improvement activities in the region and facilities assigned, including reporting to senior leadership. Acts as liaison between area of responsibility and the Quality Division, vendors and user groups. Additionally, this position directs and coordinates compliance with regulatory requirements related to quality management. WHAT IS EXPECTED (Essential Functions): QUALITY AND PATIENT SAFETY PLAN FACILITATION Initiates, oversees, and continuously evaluates a comprehensive Quality and Patient Safety program inclusive of data analysis and opportunity identification. Gathers and analyzes the appropriate internal and external information to prioritize and fund regional projects. Facilitates senior leadership oversight of the Quality and Patient Safety Plan via design, implementation and reporting of quality and patient safety initiatives with accountability for distribution of organizational communication vertically and horizontally within the facility and the system. In conjunction with medical staff leadership, directs and coordinates safety, quality and performance improvement initiatives. Serves as the liaison to the Regional Executive Team and CMO regarding regional based issues and activities. Establishes a climate that reduces obstacles and allows and promotes staff to formulate and practice own initiatives and perform at maximum achievement level. Collaborates with colleagues to provide patient satisfaction, financial and other data to promote a balance review of quality and patient safety initiatives. MEETING REGULATORY REQUIREMENTS Assesses program compliance with accreditation standards and regulations related to clinical care in collaboration with facility leadership and staff. Identifies areas of vulnerability and directs the development of strategies to enhance compliance. Coordinates hospital clinical compliance activities to ensure that hospital is in compliance with all required standards and has an integrated, consistent plan for continuously complying with all required CMS, Texas Administrative Code and Joint Commission standards. Provides direction to hospital leadership in order to maintain readiness of assigned hospital(s) for all random and/or unannounced surveys by The Joint Commission, TDSHS and other regulatory agencies. Proactively educates leadership and staff regarding new regulatory requirements related to quality and patient safety. REPORTING AND COMMUNICATION Works with medical and clinical leadership to organize, design, and present reports on quality and patient safety initiatives. Identifies key points of variation or lack of reliability in processes and facilitates process analysis. Effectively communicates activities and shared learning's vertically and horizontally. Conducts annual evaluation of program and provides Annual Report to System QPSC regarding patient safety and quality management. Serves in the role of key liaison with marketing and IS in the submission and response to publicity reported data. MANAGEMENT RESPONSIBILITIES Manages the department budget effectively and determines fiscal requirements. Prepares operating and capital budget recommendations. Participates as needed on key committees supporting quality and patient safety (Environmental Safety Committee, Quality and Patient Safety Councils, Tracers, etc.) Maintains momentum of QPS activities. Utilizes the Chain of Command if progress on QA/QC/QI or patient safety initiatives is stalled. Maintains strict confidentiality of information acquired in the course of duties. Serves as a role model for the division principles (process focus, fact based decision making, and teamwork, non-punitive) and promotion of the culture of patient safety. Performs other related duties incidental to the work described above in a professional and courteous manner. MEDICAL STAFF PEER REVIEW Participates as needed in the Medical Staff Peer Review Program supporting data collection, analysis and aggregation at appointment and reappointment cycles. Collaborates with Risk Management to assure information used in analysis and process or performance improvement enjoys the privacy and confidentiality protection afforded by law. Serves as the key leader and facilitator of the Quality and Patient Safety Plan as it applies to the Northern Regional and Central Clinics. Serves as the key leader and facilitator of the Quality and Patient Safety Plan as it applies to the Temple Memorial Hospital facility. Completes mock tracers for the region to identify areas for improvement. PERFORMS OTHER POSITION APPROPRIATE DUTIES AS REQUIRED IN A COMPETENT, PROFESSIONAL AND COURTEOUS MANNER. KNOWLEDGE, SKILLS, AND ABILITIES: Master's degree (e.g., MA, MS, MBA, MSN, MSW) or equivalent (e.g., CPA, PE, etc.) preferred. Graduate of an accredited school of nursing or other clinical professional field with current licensure required. Current CPHQ certification or eligibility for certification within 12 months of hire required. Registered Nurse (RN) preferred. Experience in an acute care or office based clinical practice required. Quality, management or supervisory experience preferred. Project management, knowledge and application of quality tools and methods, working knowledge of key quality and regulatory agencies (JCAHO, IHI, NAHQ, NCQA), and strong speaking and presentation skills required. The information contained in this job description is intended to describe the essential job functions required of those assigned to this job. It is not intended to be an exhaustive list of all responsibilities, duties, knowledge, skills, and abilities needed to perform the job. Please note that management retains the right to assign or reassign duties and responsibilities to this job at any time. The ability to competently perform all the essential duties of the position, with or without reasonable accommodation, demonstrated commitment to effective customer service delivery, integrity, and the ability to work productively as a member of a team or work group are basic requirements of all positions at Baylor Scott & White Health.

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About Baylor Scott & White Health

Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. With a commitment to and a track record of innovation, collaboration, integrity and compassion for the patient, BSWH stands to be one of the nation’s exemplary health care organizations. Our mission is to serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing. Joining our team is not just accepting a job, it’s accepting a calling!

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