Reporting to the Regional Director of Quality, this position provides leadership and is responsible for the facility-wide implementation of the Quality and Patient Safety Program that aligns with the strategic initiatives of the Baylor Scott & White Health System. The Director facilitates all aspects of quality assurance, quality control, and quality improvement activities at Baylor Scott & White Medical Center – Round Rock, including reporting to senior leadership. Additionally, this position directs and coordinates compliance with regulatory requirements related to quality management.

QUALITY AND PATIENT SAFETY PLAN FACILITATION

• Initiates, oversees, and continuously evaluates a comprehensive Quality and Patient Safety program inclusive of data analysis and opportunity identification.
• Facilitates senior leadership oversight of the Quality and Patient Safety Plan via design, implementation and reporting of quality and patient safety initiatives with accountability for distribution of organizational communication vertically and horizontally within the facility and the system.
• In conjunctions with medical staff leadership, directs and coordinates safety, quality and performance improvement initiatives.
• Serves as the liaison to the Associate Executive Director and CMO regarding facility based issues and activities.
• Collaborates with colleagues to provide patient satisfaction, financial and other data to promote a balance review of quality and patient safety initiatives.

MEETING REGULATORY REQUIREMENTS

• Assesses program compliance with accreditation standards and regulations related to clinical care in collaboration with facility leadership and staff. Identifies areas of vulnerability and directs the development of strategies to enhance compliance.
• Proactively educates leadership and staff regarding new regulatory requirements related to quality and patient safety.

REPORTING AND COMMUNICATION

• Works with medical and clinical leadership to organize, design, and present reports on quality and patient safety initiatives. Identifies key points of variation or lack of reliability in processes and facilitates process analysis.
• Effectively communicates activities and shared learning's vertically and horizontally within the facility and the system.
• Conducts annual evaluation of program and provides Annual Report to System QPSC regarding patient safety and quality management.
• Serves in the role of key liaison with marketing and IS in the submission and response to publicity reported data.
• Maintains facility intranet and internet quality and patient safety websites.

MANAGEMENT RESPONSIBILITIES

• Manages the department budget effectively and determines fiscal requirements. Prepares operating and capital budget recommendations.
• Participates as needed on key committees supporting quality and patient safety (Environmental Safety Committee, Quality and Patient Safety Councils, Tracers, etc.)
• Maintains momentum of QPS activities. Utilizes the Chain of Command if progress on QA/QC/QI or patient safety initiatives is stalled.
• Maintains strict confidentiality of information acquired in the course of duties.
• Serves as a role model for the division principles (process focus, fact based decision making, and teamwork, non-punitive) and promotion of the culture of patient safety.
• Performs other related duties incidental to the work described above in a professional and courteous manner.

MEDICAL STAFF PEER REVIEW

• Participates as needed in the Medical Staff Peer Review Program supporting data collection, analysis and aggregation at appointment and reappointment cycles.
• Collaborates with Risk Management to assure information used in analysis and process or performance improvement enjoys the privacy and confidentiality protection afforded by law.
• Serves as the key leader and facilitator of the Quality and Patient Safety Plan as it applies to the Northern Regional and Central Clinics.
• Serves as the key leader and facilitator of the Quality and Patient Safety Plan as it applies to the Temple Memorial Hospital facility.
• Completes mock tracers for the region to identify areas for improvement.

QUALIFICATIONS

• EDUCATION: Bachelors Degree is required; Masters preferred
• EXPERIENCE: 5+ Years of experience 
• CERTIFCATION/LICENSE/REGISTRATION: Professional Healthcare Quality (CPHQ) certification is required within (1) year of hire
• Registered Nurse (RN) certification is preferred

For confidential consideration, please contact:

Stacey Barbee Williams

Executive Recruiter

Stacey.Barbee@BSWHealth.org