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Job Purpose: The Director Clinical / Quality Management is responsible for conducting assessments of medical STAFFnd hospital clinical outcomes, identifying opportunities for improved patient safety, clinical quality, operation performance, and facilitating processes to prioritize and act upon improvement priorities. The Director Clinical / Quality Management will incorporate the clinical and operational benchmarking systems, patient safety program, regulatory organizations' quality / patient safety requirements, and Joint Commission readiness in the assessment, prioritization, and improvement initiatives. The Director Clinical / Quality Management is responsible for communicating and reporting medical STAFFnd hospital performance related to quality, clinical outcomes and patient safety to the medical staff, hospital staff, and administration. The Director is responsible for assuring that data required for submission to meet regulatory requirements is valid, reliable, accurate, and timely. The Director will be responsible for coordinating efforts to maintain organizational compliance with Joint Commission standards related to medical staff, performance improvement, and national patient safety goals.

Knowledge and Experience Required:

Related Work Experience:

+ Minimum five (5) years work experience in health care quality management, quality improvement, clinical outcomes, or hospital performance improvement

Education:

+ BA / BS degree required

Licenses and/or Certifications Required:

+ Certified Professional in Health Care Quality - CPHQ and/or CPPS

+ Certified Risk Management, or Infection Control

Licenses and/or Certifications Preferred:

+ If basic education relates to a licensed health profession, then license must be current

Job Responsibilities:

+ Coach, mentor, and develop staff: Establish, in conjunction with MHS values, policies, ethics, and departmental operating guidelines; Establish and communicate department goals and accomplishments, incorporation individual and team efforts in formal and informal feedback and recognition programs; Create an atmosphere of collaboration within the department and organization.

+ Coordinate and/or assist with the implementation of programs to improve patient safety: Analyze occurrence reports, near miss reports, sentinel events reviews and failure mode effects analysis to identify areas of actual/potential of patient safety hazards; Uses reports from other sources for organizational application and adoption of patient safety practices (e.g. Web M&M, ISMP, Joint Commission, Leapfrog, National Quality Forum, Institute for Healthcare Improvement); Facilitates organizational prioritization of patient safety initiatives; Coordinates organizational adoption of national patient safety goals.

+ Facilitate / co-lead clinical improvement teams, fostering identification of needed improvements and integration with interdisciplinary teams as needed: Develop education and development program to assist managers, directors, supervisor, staff, and physicians to effectively respond to identified improvements required; Directs, manages, and maintains the medical staff peer review process of medical staff members on a current basis and reports medical staff issues as required.

+ Integrate benchmarking, hospital quality initiatives, medical management, patient safety and JCAHO preparation with medical STAFFnd hospital quality initiatives: Educate medical STAFFnd hospital staff regarding performance improvement processes/initiatives; Anticipate and integrate quality measures, which may be publicly reported or will tie to pay for performance for the hospital or medical staff, into ongoing assessment and improvement activities; Assure timely and accurate data collection to meet requirements for state, federal, other initiatives (e.g. Hospital Quality Initiatives); Develop a systematic approach to use of benchmark data by the medical STAFFnd hospital staff which will result in and support prioritization of needed improvement activities; Assure that prioritized performance improvement initiatives are supported by appropriate structure, charters, methodologies, accountability and feedback mechanisms; Evaluate effectiveness of performance improvement efforts; Revise performance improvement methods to achieve targeted results.

+ Maintain current knowledge of federal, state, hospital and Joint Commission standards related to quality, clinical outcomes, and patient safety: Coordinate and/or assist with policy/guidelines development to assure compliance with external regulations; Coordinate and/or assist with required reporting of patient care-related incidents to the Texas Department of State Health Services; Coordinate responses to Texas Department of State Health Services, Centers for Medicare/Medicaid Services, and/or Joint Commission requests for data, on-site reviews, and action plans to correct deficiencies; Submit required follow-up reports to Joint Commission, state and federal agencies.

+ Maintain fiscal responsibility for departmental operations: Direct the development, implementation and evaluation of the department budget; Establish processes for orientation, ongoing development, and competency verification of personnel.

+ Maintain organizational compliance with Joint Commission standards related to medical staff, infection control/prevention, and performance improvement functions and national patient safety goals. Assist with organizational survey readiness activities: Conduct ongoing readiness assessment using the “periodic performance report“ (PPR) tools and other aides provided by Joint Commission, MHS JCAHO readiness activities, for performance improvement, infection control, and national patient safety goals; Provide education, coaching etc to help medical and hospital staff meet medical staff, performance improvement, infection control, and national patient safety goal standards; Support tracer surveys, department-based mini-surveys, mock surveys. Support may be evident through participating in, leading, or coordinating any of the above; Assist in coordinating Joint Commission surveys; Coordinate the organization's response to Joint Commission survey findings.

+ Optimize the medical staff's quality program. Use performance improvement processes to assure ongoing evaluation and improvement of medical care through peer review, departmental goal setting, and benchmark data: Assure annual adoption of medical staff department peer review case selection criteria, rates for ongoing tracking and “rate”-related trigger points for further review, and rules requiring adherence by the medical staff; Use benchmarking data, adherence to evidenced base practices, trending of medical staff performance, to identify opportunities for improving medical staff performance; Implement and use physician profiling to assist individual physicians and medical staff departments to recognize or improve performance; Conduct timely mortality and special event screening and peer review; Provide timely and accurate data related to medical staff performance to each medical staff department; Provide timely and accurate data related to individual medical staff members when certain volume parameters have been met; Provide data to support medical staff credentialing/reappointment processes; Develop and maintain medical staff department performance reports; Conduct annual reviews of each medical staff department's performance; Coordinate the Medical Staff Quality Council activities.

Methodist Dallas Medical Center is one of North Texas’ best places to work. And it keeps getting better. The flagship hospital of Methodist Health System, Methodist Dallas is a 595-bed acute care teaching and referral hospital. It is home to the only adult Level I Trauma Center in southern Dallas, the first and only Certified Comprehensive Stroke Center in southern Dallas, and the newly renovated Linda and Mitch Hart Breast Center. Celebrating more than 90 years of service, we strive to have a diverse workforce that reflects the communities we serve and welcomes the skills and talents of all groups. Our reputation as an award-winning employer shows in the distinctions we’ve earned:

+ Magnet®-designated hospital

+ 150 Top Places to Work in Healthcare by _Becker’s Hospital Review_ , 2023

+ Top 10 Military Friendly® Employer, Gold Designation, 2023

+ Top 10 Military Spouse Friendly® Employer, 2023

+ Level III Neonatal Intensive Care Unit

+ Liver, kidney, and pancreas transplantation programs

Methodist Health System is a faith-based organization with a mission to improve and save lives through compassionate, quality healthcare. For nearly a century, Dallas-based Methodist Health System has been a trusted choice for health and wellness. Named one of the fastest-growing health systems in America by _Modern Healthcare_ , Methodist has a network of 12 hospitals (through ownership and affiliation) with nationally recognized medical services, such as a Level I Trauma Center, multi-organ transplantation, Level III Neonatal Intensive Care, neurosurgery, robotic surgical programs, oncology, gastroenterology, and orthopedics, among others. Methodist has more than two dozen clinics located throughout the region, renowned teaching programs, innovative research, and a strong commitment to the community. Our reputation as an award-winning employer shows in the distinctions we’ve earned:

+ TIME magazine Best Companies for Future Leaders, 2025

+ Great Place to Work® Certified™, 2025

+ Glassdoor Best Places to Work, 2025

+ PressGaney HX Pinnacle of Excellence Award, 2024

+ PressGaney HX Guardian of Excellence Award, 2024

+ PressGaney HX Health System of the Year, 2024

Equal Opportunity Employer

It is the policy of Methodist Health System (MHS) to select, develop, and promote employees based on individual ability and job performance. It has been, and will continue to be, the policy of MHS to provide equal employment opportunity to all people in all aspects of employer-employee relations without discrimination because of race, color, religion, national origin, age, sex, sexual orientation, gender expression, disability, marital status, genetic information or ancestry. This policy affects decisions including, but not limited to, an employee’s compensation, benefits, terms and conditions of employment, opportunities for promotion, training, development, transfer all other privileges of employment. MHS is committed to maintain a working environment free of intimidation, workplace discrimination and harassment. Retaliation or attempted retaliatory behavior that occurs as a result of an employee’s exercise of their rights under this policy or any other statutorily protected right is strictly prohibited and will be grounds for disciplinary action.