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Job Purpose:The Director of Quality will provide leadership, strategic direction and operational management for all aspects of quality. This individual has oversight and responsibility for quality, risk management, and patient safety related activities within the organization. Directs the efforts of performance improvement initiatives to ensure overall compliance with regulatory standards including local, state, and federal agencies. Responsible for the facilities quality, patient safety and risk management programs with an emphasis on patient safety and reducing harm. Supports, promotes and encourages a culture of safety throughout the organization. Leads and directs the work of others and demonstrates strong communication and collaboration with stakeholders at all levels of the organization. Reports to the Chief Operating Officer.

Education & Qualifications:

• Bachelor’s Degree Clinically related discipline required. Master’s degree Business, Healthcare Administration or clinically related discipline Preferred.
• Knowledge of managed care, government payers, third party reimbursement, payer requirements, evidence-based standards for quality improvement and delivery of services to patients.
• Skills in strategic planning, operational execution, strong relationship building.
• Ability to perform outcomes analyses and reporting, managing multiple projects and meeting deadlines.
• Knowledge of healthcare quality programs, performance improvement/ change management principles and methods, statistical process control and use of data analysis to drive improvement.
• Strong interpersonal skills and the ability to collaborate and problem solve. Ability to work in a high-volume environment and provide effective, efficient leadership and customer service to all stakeholders.

Required Licenses/Certifications:

Other Licensure as required by the State of Texas for clinical discipline upon hire required. CPHQ – Certified Professional in Healthcare Quality Upon Hire Preferred.

Work Experience:

• 5 Years Progressive management experience in healthcare field inclusive of quality, patient safety, and/or risk management required and 3 Years performance improvement experience with proven accomplishments and outcomes required.
• Experience in a highly reliable organization (HRO) Preferred.
• Nurse Experience Strongly Preferred

Essential Duties and Responsibilities:

• Responsible for all aspects of management of the staff dedicated to Quality, Risk Management, Infection Control, Employee Health, and Medical Affairs. Scope is subject to change based on hospital operations.
• Evaluate the performance of department staff and provide constructive feedback and counseling when appropriate.
• Implements best practices for effective quality of care by ensuring evidence-based protocols and standards are in place and identifies progress toward desired care outcomes.
• Coordinate, manage, and report Core Measures and other quality metrics.
• Manage and facilitate the onboarding of medical staff to the organization.
• Participate in nursing and physician peer review processes, as necessary.
• Establishes effective communication systems and forums with third party payers to facilitate process improvement.
• Oversee patient and customer grievances processes and resolution based on CMS regulations.
• Manages the financial performance, and identifies and implements appropriate strategies to reduce costs, and improve quality of care and services. Participates in budget preparation and management for the quality department.
• Lead infection control activities in collaboration with the infection control team.
• Directs the employee health program in collaboration with Human Resources.
• Review, investigate and analyze incidents for risk and adverse event identification, loss prevention and claims management purposes, including both potential and actual patient injury.
• Assists in the establishment of operational performance measurements and the monitoring of trends in key performance indicators to evaluate effectiveness, reliability, efficiency, etc., using available information systems data.
• Focuses on prevention, intervention and identification of issues prior to their impact on operations and patient care. Recommends and develops new programs for specialized patient populations to improve quality and effectiveness.
• Uses data analysis to monitor key performance indicators, identifies and initiates performance improvement plans for achieving goals and targets
• Partners with medical directors, operational leaders, physicians and staff to provide education and guidance for data analysis and improvement of key quality metrics and initiatives.
• Performs other duties as assigned.