**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 Heart and Vascular, Arlington, TX + Core work hours: Monday-Friday 8:00a-5:00p **Summary** Constant focus on promoting a culture of safety, high-reliability, and performance excellence while overseeing implementation and operation of Quality & Patient Safety initiatives. **Job Duties** OPERATIONS: ACCREDITATION/CLINICAL CERTIFICATION - Oversight and facilitation of data submission for TJC accreditation activities, liaise with TJC, CMS and the Texas Health and Human Services, Direct Chest Pain Certification programs and activities, Oversight of GWTG HF and AMI registries, implementation and data submission (HARP/QNet) THCIC state reporting, Oversight of carotid artery stent clinical trial, data submission for cancer registry. Core measure reporting (vaccination, Sepsis, ED), conducts chart audits and tracers with staff to determine current state of regulatory readiness and compliance, identify areas of improvement and relate to senior leadership. OPERATIONS: Quality/PI/PATIENT SAFETY - Direct and support processes and coordinate tactics that advance patient safety, educate and promote HRO tactics, and performance improvement - Track, trend and monitor performance improvement outcomes and risk events (RL) - Work with other departments on hospital and system initiatives and support evidence-based best practices - Ensure annual completion of FMEA - Direct clinical outcomes program. As best practices and/or identified opportunities arise, lead the team to conduct PDSA's and follow the process to ensure that efforts are effective and maintained. Collect and analyze continuous improvement data for contracted services, including identifying opportunities for improvement and working with each department to develop a resolution, Presents annual contract evaluations to the Board. Track and trend RL events, manage reports, handle grievances per state guidelines, develop reports and presentations for senior leadership meetings. OPERATIONS: PEER REVIEW - Oversee and facilitate Medical Staff Peer Review, including Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) - Assist peer review physicians and division chiefs in preparing and presenting case reviews and completing follow-up activities based on peer review findings. Oversee and facilitate Mortality and Morbidity Review as part of OPPE/FPPE process. Follow-up on RL events that require Peer Review. HUMAN RESOURCES - Develop and implement strategy to create and maintain a positive employee relations environment for departmental employees - Recruit, orient and retain excellent staff - Supervise departmental staff, developing standards of performance, evaluating performance and initiating or recommending personnel actions - Mentor job-related growth of staff. LEADERSHIP - Plan and execute in collaboration with Chief Medical Officer, Chief Nurse Executive the implementation of a comprehensive quality and safety management process - Develop and maintain KPI quality dashboard - Direct the preparation and maintenance of department reports and tracking of data for quality and safety initiatives, including preparation of reports for committees and top management as required - Monitor and supervise hospital compliance with The Joint Commission (TJC) and governmental agencies, standards and requirements, acting as liaison during site reviews - Participate in and represent hospital in system-wide quality/patient safety committees and initiatives - Take initiative and coordinate with other departments to develop action plans for performance improvement and patient safety initiatives and risk reduction. OPERATIONS: ASSIST IN INVESTIGATION/RESPONSE TO SENTINEL EVENTS/NEAR MISSES - Conduct initial investigation of events to begin information gathering process - Work with CNO/hospital staff/medical staff regarding management of event and communication with the patient/family - Communicate with the patient/family as necessary - Coordinate and facilitate RCA meetings and development of action plans - Monitor progress and effectiveness of RCA Action Plans - develop reports and results of action plans for Risk Medical Executive Committee/Board/Department meetings. **Education** Bachelor's Degree Clinically related discipline required Master's Degree Business, Healthcare Administration or clinically related discipline preferred **Experience** 2 years supervisory and progressive management experience in quality and risk management. Previous experience managing physician relationship. Results with proven accomplishments and outcomes improvement required 5 years in healthcare field inclusive of quality, patient safety, and/or risk management required **Licenses and Certifications** RN - Registered Nurse required upon hire CPHQ - Certified Professional in Healthcare Quality or CPHRM - Certified Professional in Healthcare Risk Management preferred upon hire **Skills** Knowledge of industry standards related to Joint Commission, CMS, OSHA, regulatory standards for areas of responsibility. Knowledge of continuous improvement tools and techniques, inclusive of contemporary models (six sigma, lean, clinical microsystems as examples). Must be able to analyze and manage information. Excellent verbal/presentation and written skills with the ability to communicate effectively with a wide variety of professional and non-professional stakeholders. Able to supervise a diverse and independent staff. Individual must be self-directed and goal/outcomes/measurement driven. **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. \#LI-AZ1 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.