Director Quality Patient Safety and Risk

Director Quality Patient Safety and Risk

Are you looking for a rewarding career with familyfriendly hours and topnotch benefitsWere looking for qualifiedcandidateslike you to join our Texas Health family.

• Work location: Texas Health Southwest
• Core work hours: Monday Friday; 8:00a5:00p

At Texas Health Southwest and Texas Health Clearfork were one hospital in two locations. Were a 261bed fullservice 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 24hour 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 5Star rating the US News & World report top hospital award and multiple awards for STEMI/NSTEMI.

Position Summary

The Director of Quality Patient Safety and Risk Management will serve as a resource for Texas Health Southwest Hospital by offering valueadded knowledge and expertise in improving outcomes and providing safe timely costeffective personcentered 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 Description

Regulatory Accreditation & Certification
1 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 interrater reliability processes.
2. Works in collaboration with hospital leadership to ensure that all required regulatory/certification submissions and followup 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.
3. 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.
4. 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 evidencebased practice and current best practices.
Performance & Process Improvement
1. 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.
2. Promotes the use of Process and Performance Improvement methods and science throughout the hospital
3. 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 jobrelated growth of staff.

Performance & Process Improvement
1. 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.
2. Promotes the use of Process and Performance Improvement methods and science throughout the hospital
3. Provides education and guidance on the purpose use and value of quality improvement tools.
Population Health & Care Transitions
1. Participate in the development of population health improvement models and strategy.
2. Advise leadership on the impact of evolving payment models and their associated quality metrics for strategic planning and development priorities.
3. Integrate population health improvement initiatives and metrics into the hospital quality program.
4. Lead prioritization activities to identify target populations for improvement of care delivery.
Health Data & Analytics
1. Leverages electronic systems to input analyze extract and manage data to support and drive data integrity streamline process innovate practices and achieve positive outcomes.
2. Develops hospital reports and scorecards incorporating clinical and business metrics tailored to strategic or operational goals.

Patient Safety / Risk Management
1. Promote a safety culture and infrastructure that aligns with Texas Healths strategic objectives and meets regulatory/accreditation standards.
2. Identifies opportunities for improvement and continuously looks for ways to improve processes and reduce harm using the principles of High Reliability.
3. Conducts and develops comprehensive risk assessments prioritizes potential risks and recommends evidencebased 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
5. Peer Review management and oversee patient grievances.
Quality Review & Accountability
1. Provides oversight of the annual assessment and development of the Texas Health Southwest Quality Assurance Performance Improvement (QAPI) plan.
2. Develop and oversee processes for managing professional practice evaluation information across its life cycle from capture to archive and/or destruction.
3. Incorporate findings from identified trends across ongoing professional practice evaluation and peer review into performance improvement activities across the organization.
4. Synthesize requirements from multiple regulatory and/or payer agencies and communicate organizational impact across various programs.

Professional Engagement
1. Pursues/achieves/maintains required applicable certification and licensure.
2. Pursues professional growth and development of required knowledge and skills.
3. Participates in a Quality/Regulatory professional organization.

Leadership & Integration
1. Utilizes the principles of influence leadership and change management to advance program goals and ensure changes are vetted by all stakeholder groups.
2. Utilizes skills in communication relationshipbuilding and facilitation to ensure that all stakeholders feel accountable for performance improvement continuous regulatory compliance and patient safety
3. Contributes to the development of other stakeholders through education and mentorship.

Education
Bachelors Degree Clinical/Healthcare AdministrationRequired
Masters Degree Clinical/Healthcare Administration Preferred

Experience
7 Years Clinical or operational experience in a hospital setting Required
and
5 Years Progressive operational/program management experience Required
3 Years Functioning at an Integrated Health System level
High reliability organization (HRO) experiencePreferred

Licenses and Certifications
CPHQ Certified Professional in Healthcare Quality with in 12 Months of hire Preferred
Or
CPHRM Certified Professional in Healthcare Risk Management with in 12 Months of hire Preferred

Skills
Excellent 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 applications

Why 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 28000 employees were one of the largest employers in the Dallas Fort Worth area. Our career growth and professional development opportunities are topnotch 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 more about our culture benefits and recent awards.

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