Director Quality Improvement is accountable for planning, directing, and coordinating quality and patient safety improvement programs for Baylor Scott and White Health (BSWH), which include systematic improvement activities that drive toward zero preventable harm and values of safe, timely, effective, efficient, equitable, and patient centered health care services. Develops and implements improvement plans, programs, procedures, and practices that improve the quality of patient care at BSWH hospitals, clinics, and ambulatory care facilities. Reviews current programs and seeks opportunities to improve and resolve clinical quality problems or operational issues for assigned area of responsibility. Develops key metrics of clinical quality and patient safety and directs the testing, trending, forecasting, and reporting of data to improve health care processes. Ensures clinical performance improvement programs are compliant with all regulatory, legal, and organizational requirements. Partners with clinical staff, operations, and other stakeholders to improve processes that impact patient safety and the quality of patient care at BSWH.
An entity Director translates and implements strategic plans and goals for area of responsibility. Makes final decisions on operational matters and ensures achievement of goals. Recommends policies and organizational changes for area. Plans and executes projects and initiatives that meet annual goals. Erroneous decisions at this level tend to have negative impact on the success of the area, business unit, and possibly the overall organization's operations. Plans and directs the operations of a department or area, with responsibility for staffing, processes, budgets, and costs of the unit. Leads and advises subordinate(s) to meet schedules, resolve technical problems, and monitor performance. Has a larger, more complex organization or functional area than a manager. Often has one or more managers or supervisors reporting to the role.
ESSENTIAL FUNCTIONS OF THE ROLE
Directs the quality improvement function for assigned area of responsibility for BSWH.
Leads cross-functional teams including patient safety, infection prevention, nursing, risk management, nursing, and medical staff, and other stakeholders to promote continuous improvement in quality and patient safety for assigned area.
Directs, facilitates, and helps hospital quality improvement and patient safety committees and councils that give oversight to ensure high quality and safe patient care.
Leads 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 local, state, and national initiatives related to population health and care Leads quality improvement analytics, data validation, and data analysis activities, including data submission and testing for facility identified data registries and ensuring confidentiality of all data, presentations, and reporting.
Leads the identification of real and potential safety concerns in all BSWH facilities and directs helping programs that include variance reporting, patient safety response, and compliance activities with all state and federal safety regulatory requirements.
Partners with clinical and corporate compliance to lead regulatory accreditation/certification surveys, disease specific certifications/designations, onsite or desk review clinical surveys (federal, state, and local entities), and other federal, state, or local compliance requirements.
Establishes hospital and system processes to monitor quality and patient safety targets and ensures that all reporting requirements are met, engaging with internal and external stakeholders as required.
KEY SUCCESS FACTORS
Bachelor?s degree in healthcare management, nursing, business, or related field preferred. Master?s degree preferred.
3+ years of experience in healthcare quality improvement, patient safety, risk management, or related area.
Experience in a leadership role preferred.
Experience in leading interdisciplinary initiatives in process improvement.
Knowledge of healthcare quality, patient safety management, benchmarking, and outcome measurement.
Knowledge of statistics, data collection, testing, and data presentation.
Critical thinking, process testing, and problem-solving skills.
Excellent written, verbal, and presentation skills.
BENEFIT
Our competitive benefits package includes the following
Immediate eligibility for health and welfare benefits
401(k) savings plan with dollar-for-dollar match up to 5%
Tuition Reimbursement
PTO accrual beginning Day 1
Note: Benefits may vary based on position type and/or level
QUALIFICATIONS
EDUCATION - Bachelor's or 4 years of work experience above the minimum qualification
Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. With a commitment to and a track record of innovation, collaboration, integrity and compassion for the patient, BSWH stands to be one of the nation’s exemplary health care organizations. Our mission is to serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing. Joining our team is not just accepting a job, it’s accepting a calling!
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NAHQ wants to partner with you and your organization as you explore how to elevate the profession and advance the discipline of healthcare Quality & Safety.
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For customer service issues, contact us at info@nahq.org or call us at (847) 375-4720. The team is available Monday-Friday from 8 AM-4:30 PM CT.
Important Information for CPHQ Recertification
The recertification process has been streamlined. Unlike previous years, you don’t need to list out your CE activities at the time of completing your application. Instead, you will be asked to attest to having met the requirements, further aligning with the honor-based system of recertification. In the event that your application is randomly selected for audit, you may be required to list your CE activities and submit supporting documentation.
While you may participate in NAHQ learning opportunities (Learning Labs, JHQ articles, etc.), you can only claim CE credit once for each activity. Therefore, if you’ve previously earned CE from a NAHQ learning opportunity, you can’t claim it again, nor will you see the repeat CE appear in your “My Learning� tab. This includes activities used in previous recertification cycles.
Remember, if you’re recertifying during the grace period (1/1/24-1/31/24), you already had to earn your CE hours by Dec 31, 2023.
You still have time! Register today for a multi-day virtual event that addresses the most urgent and important issues facing healthcare today that offers a full schedule of educational sessions organized around NAHQ’s twice-validated healthcare quality competency framework.
We are excited to announce the release of the book “UNSTOPPABLE: Inspiring Stories of Perseverance, Triumph and Joy from Trailblazing Women in Healthcare“.
Be inspired by nine leading healthcare trailblazers, including our own CEO Stephanie Mercado, who empower us all with their vision and passions.
You’ll notice we’ve simplified the application process to recertify. You will not have to list your CE activities at the time of applying*. Simply attest that you met the requirements to complete the application.
*In the event of an audit, CPHQs may need to list activities and upload documentation in their NAHQ account.
Quality Education Resources
Join this informative session, “Quality Education Resources� Thursday, June 22 from 11-11:30 a.m. CT. You will learn about the range of NAHQ quality education resources available to you and hear directly from universities about the benefits they realized from implementing NAHQ’s content within their courses.
Maintain a Pulse on the Latest Quality & Safety Benchmarking Data
Learn more about NAHQ’s enhanced Quality and Safety Benchmarking Program, which provides timely insights to help U.S. hospitals and health systems create data-driven business cases for their quality and safety resourcing.
Understand the Variability Among Your Quality Team Through Workforce Accelerator
Join us Tuesday, May 2, at 11 a.m. CT, to learn more about the different options available to engage with NAHQ’s enterprise-wide solution, Workforce Accelerator®. Options range in size and scope and are designed to meet the various budgetary and timing needs of health systems as they embark on their quality journeys. Register today!
Healthcare Quality and Safety Workforce Report: New Imperatives for Quality and Safety Mean New Imperatives for Workforce Development
The National Association for Healthcare Quality® (NAHQ) has conducted groundbreaking research on the advancement of the quality and safety agenda and has published the results in a new workforce report. NAHQ’s Healthcare Quality and Safety Report answers the question: “Is today’s healthcare workforce doing the work that will advance critical priorities of quality, safety, equity, value, and system sustainability?� The answer is no.
Updated Maintenance Dates: Sunday, February 5, 2023
Maintenance is planned for Sunday, February 5, from 11 p.m.-4 p.m. CT. During this time, you will not have access to the “My Learning” section of your NAHQ account. We apologize for any inconvenience this may cause and thank you for your patience.
NAHQ’s Organizational Membership Subscription will serve as a one-stop shop for healthcare quality and safety training and education. Attend the February 2, at 11 a.m. CT, info session to further understand the new offering that will continue NAHQ’s focus of “Quality in Action.�
NAHQ has published an updated version of the CPHQ exam content outline.
The new exam content will take effect on March 15, 2023. Candidates planning to take the exam before March 15, 2023, can access the current CPHQ exam content outline and related resources on our website.
Missed NAHQ Next? Don’t worry, you can purchase NAHQ Next on-demand and receive access to all content for 60 days from purchase. Benefit from actionable content that addresses issues head-on and features “how-tos” and results. Buy now and have the opportunity to receive 40+ CEs.
Healthcare Quality and Safety Workforce Report: New Imperatives for Quality and Safety Mean New Imperatives for Workforce Development
Member Briefing Workshop and Healthcare Quality Week Webinar
October 7, at 12 p.m. CT
NAHQ will host an exclusive member briefing workshop where NAHQ CEO Stephanie Mercado and NAHQ President-Elect Nidia Williams will review the workforce report in-depth and prepare you to discuss it with your team and leadership during Healthcare Quality Week.
October 17, at 12 p.m. CT
To kick off Healthcare Quality Week, (HQW) NAHQ will host a complimentary webinar with NAHQ leaders to discuss the report, its impact and how you can leverage the report to your advantage.
You still have time! Register today for a multi-day virtual event that addresses the most urgent and important issues facing healthcare today that offers a full schedule of educational sessions organized around NAHQ's twice-validated healthcare quality competency framework.