Director - Centers of Excellence

Job Description

 

The Director of Centers of Excellence (COE) is a healthcare leadership role responsible for overseeing the design, implementation, and continuous improvement of clinical programs and outcomes. Director of the COE will be responsible for certifications, designations, and accreditations within MMH related to the Level III Trauma and the Cardiac Clinical programs. This position is in West Texas serving a 540-bed hospital ensuring compliance with State of Texas Designations, Certifications, and Federal programs. This role will coordinate multi-disciplinary care, drive quality, safety, and performance improvement initiatives for trauma and cardiac quality programs that require certification/designations and registry management. Leading a multi-disciplinary team to support the care and treatment of the communities that we serve.

 

SHIFT & SCHEDULE

Full Time, Monday - Friday; 8:00 AM - 5:00 PM

 

 

ESSENTIAL FUNCTIONS/PERFORMANCE EXPECTATIONS

Core Responsibilities

1. Program Leadership & Compliance

· Leads the trauma program in alignment with Texas Trauma System designation and re-designation requirements and assures designation requirements are met

· Leads the Cardiac Quality program, manage all registries, and disease specific certifications and assures all certifications and designations are maintained

· Works with all levels of leadership and front-line staff to facilitate and support the development and integration of evidence-based practices

· Maintain and update protocols, policies, and procedures to meet evolving standards related to overall Quality improvements

· Serve as liaison with the Trauma and Cardiac Medical Director(s) and hospital administration

· Supervise cardiac quality and trauma direct reports consisting of multiple teams

 

2. Quality & Safety Oversight

· Oversee daily operations of the trauma and cardiac quality service lines to ensure optimal patient care and outcomes

· Monitor quality, safety, and appropriateness of trauma and cardiac care

· Works in partnership with Quality Department to ensure accurate public reporting of data

· Maintain and update protocols, policies, and procedures to meet evolving standards related to overall specific program improvements

· Implement and manage Performance Improvement (PI) programs for trauma care teams utilizing nationally accepted frameworks and processes

· Chair or co-chair multidisciplinary committees (e.g., Trauma System Improvement Committee, Cardiac Clinical Improvements Committee)

 

3. Interdisciplinary Coordination

· Coordinate activities across clinical specialties involved in trauma/cardiac care to ensure efficient and effective resource use

· Strong partnership and responsibility to the Trauma Program Medical director, Cardiac Program Medical Director and surgical services leadership teams

· Foster collaboration between hospital departments, EMS, and regional trauma centers

· Actively participates in all accredidation, certifications and regulatory activities

· Works with all community partners to support the program(s) both regionally and statewide

 

4. Data Management & Registry

· Manage trauma registry data, injury prevention initiatives, and outcome reviews

· Use data to drive evidence-based improvements and research opportunities

 

5. Education & Outreach

· Lead or participate in trauma/cardiac education for healthcare providers, EMS, and the public

· Promote injury prevention and community safety initiatives

· Be an active member in the “J” Rac attending all required meetings at least 80% of the time

· Support disaster preparedness and emergency response coordination in partnership with other hospitals and community-based resources

 

6. Strategic & Operational Management

· Develop strategic plans for trauma service lines, aligning with hospital and state goals

· Partner with business development, foundation and care delivery sites to implement service line initiatives

· Manage budgets, resources, and staffing needs for trauma and cardiac quality care

· Operationalize a plan for umbrella management of all accreditations, designations certifications and registries related to disease specific programs

 

EDUCATION AND EXPERIENCE

Required Skills & Experience

· Clinical background: A registered nurse with cardiac and /or trauma program management or trauma director experience preferred, will consider ED leadership, OR Leadership or Service line Specialty Certification Leadership background. Bachelors required, Masters required.

· Leadership competencies: Strong leadership, strategic planning, and change management skills.

· Analytical skills: Proficiency in trauma registry software and data analysis.

· Communication: Ability to communicate effectively with clinical staff, administrators, and external partners.

· Regulatory knowledge: Deep understanding of trauma and cardiac care standards, accreditation requirements, and Texas healthcare regulations.

 

Work Environment

· Level II–III trauma center (currently Level III)

· Involves collaboration with multiple departments, EMS, and regional cardiac and trauma systems.

· May require travel for state-level meetings, accreditation site visits, and training.