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Director Quality, Patient Safety and Risk

_Are 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 Cleburne

+ Core work hours: Monday - Friday; 8:00a-5:00p;

For more than three decades, Texas Health Cleburne has delivered compassionate, high-quality care to the people of Cleburne and surrounding communities. As a 137-bed, full-service hospital, we provide medical services to residents in Joshua, Godley, Keene, Grandview, Alvarado, Rio Vista, Glen Rose, and beyond.

We specialize in surgical services, women's health, orthopedics, gastroenterology, nephrology, and inpatient and outpatient rehabilitation-including physical, occupational, and speech therapy. We're also an accredited Chest Pain Center and offer exceptional emergency care 24/7.

Texas Health Cleburne is a Joint Commission-accredited hospital recognized as a Top Performer for Quality Care. We are also a designated Pathway to Excellence hospital and a certified Level IV Trauma Center. Whether you're interested in emergency medicine, surgery, or preventive care, you'll find a welcoming, supportive team at Texas Health Cleburne.

Job Qualifications

I. Regulatory Accreditation & Certification:

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.

II. 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.

III. 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.

IV. 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.

V. Patient Safety:

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.

Prioritize high risk findings in order to escalate opportunities for improvement for system leadership awareness and support of risk mitigation strategies.

VI. Quality Review & Accountability:

Provides oversight of the annual assessment and development of the Texas Health Harris Methodist Hospital Cleburne's Quality Assurance Performance Improvement (QAPI) plan.

Oversees and facilitates Medical Staff Peer Review, including Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE). Assists Medical Staff with organizing Peer Review cases and completing follow-up activities based on outcome and peer review findings.

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.

VII. 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.

VIII. 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.

Education

Bachelor's Degree Clinical related discipline Required

And

Master's Degree Clinical or Healthcare Administration Preferred

Experience

7 Years Clinical or operational experience in a hospital setting Required

and

5 Years Progressive management experience in healthcare field inclusive of quality, patient safety, and/or risk management Required

and

3 Years Functioning at Integrated Health System level

High reliability organization (HRO) experience Preferred

Licenses and Certifications

RN - Registered Nurse Upon Hire Required

And

CPHQ - Certified Professional in Healthcare Quality with in 2 Years of hire Required

Skills

Knowledge of accreditation and industry standards: Life Safety Code (LSC), The Joint Commission (TJC), Center for Medicare and Medicaid Services (CMS), National Quality Foundation (NQF), Institute for Healthcare Improvement (IHI), Texas Department of State Health Services (TDSHS), Hospital Incident Command Systems (HICS), and Federal Emergency Management Agency (FEMA).

Must exhibit a comprehensive understanding of performance improvement methodologies, theory and practice.

Demonstrated skills in strategic planning, implementing action plans, and evaluating and enhancing programs.

Ability to lead transformational change resulting in improved patient safety, high reliability and quality of care.

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 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.

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Texas 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.