Director of Quality Improvement

About Us

Here at Baylor Scott & White Health we promote the well-being of all individuals, families, and communities. Baylor Scott and White is the largest not-for-profit healthcare system in Texas that empowers you to live well. Our Core Values Are We serve faithfully by doing what's right with a joyful heart. We never settle by constantly striving for better. We are in it together by supporting one another and those we serve. We make an impact by taking initiative and delivering exceptional experience.

Job Summary

Director Quality Improvement plans, directs, and coordinates quality and patient safety programs for Baylor Scott and White Health (BSWH). These programs include activities that aim for zero preventable harm and ensure safe, timely, effective, efficient, equitable, and patient-centered care. The director develops and implements plans, programs, procedures, and practices to improve patient care quality at BSWH hospitals, clinics, and ambulatory facilities. They review current programs and seek opportunities to resolve clinical quality problems or operational issues. The director develops key metrics for clinical quality and patient safety and directs data testing, trending, forecasting, and reporting to improve health care processes. They ensure clinical performance improvement programs comply with all regulatory, legal, and organizational requirements. The director partners with clinical staff, operations, and other stakeholders to improve processes impacting patient safety and care quality at BSWH.

Essential Functions of the Role

• Directs the quality improvement function for assigned area of responsibility for BSWH.
• Manages cross-functional teams, including patient safety, infection prevention, nursing, risk management, and medical staff.
• Works with other stakeholders to promote continuous improvement in quality and patient safety for the assigned area.
• Directs, facilitates, and supports hospital quality improvement and patient safety committees.
• Manages and guides process improvement teams and activities using quality and patient safety best practices, improvement tools, and standardization methods.
• Directs data monitoring, collection, and testing and tracking and trending of care processes to ensure safety, effectiveness, and efficiency.
• PARTNERS WITH HOSPITAL AND SYSTEM TEAMS TO ADVANCE HEALTH INITIATIVES.
• MANAGES QUALITY IMPROVEMENT ANALYTICS, DATA VALIDATION, AND DATA ANALYSIS ACTIVITIES.
• This includes data submission, testing for facility-identified data registries, and ensuring data confidentiality.
• MANAGES THE IDENTIFICATION OF REAL AND POTENTIAL SAFETY CONCERNS IN ALL BSWH FACILITIES.
• DIRECTS PROGRAMS LIKE VARIANCE REPORTING, PATIENT SAFETY RESPONSE, AND COMPLIANCE WITH STATE AND FEDERAL SAFETY REGULATIONS.
• PARTNERS WITH CLINICAL AND CORPORATE COMPLIANCE TO MANAGE REGULATORY SURVEYS, CERTIFICATIONS, AND COMPLIANCE REQUIREMENTS.
• ESTABLISHES HOSPITAL AND SYSTEM PROCESSES TO MONITOR QUALITY AND PATIENT SAFETY.
• ENSURES ALL REPORTING REQUIREMENTS ARE MET.
• ENGAGES WITH INTERNAL AND EXTERNAL STAKEHOLDERS AS REQUIRED.

Key Success Factors

• Masters degree in healthcare management, nursing, business, or related field preferred.
• 5+ years of experience in healthcare quality improvement, patient safety, risk management, or related area.
• 3+ years of experience in a leadership role in healthcare quality improvement, patient safety, risk management, or related area.
• Experience in leading interdisciplinary initiatives in process improvement.
• Expertise in healthcare quality, patient safety management, benchmarking, and outcome measurement.
• Knowledge of statistics, data collection, testing, and data presentation.
• Strong emotional intelligence, critical thinking, process testing, and problem-solving skills.
• Excellent written, verbal, and presentation skills.
• Ability to adjust to needs of the audience.
• Ability to build strong, collaborative working relationships with leaders, peers, and direct reports.
• Certified Professional in Healthcare Quality (CPHQ) Expertise in CMS Pay for Performance Programs, CMS Stars, and Leapfrog.

Qualifications

• Education - Bachelor's or 4 years of work experience above the minimum qualification.
• Experience - 3 Years of Experience.