Where compassion meets innovation and technology and our employees are family.

General Purpose of Job:

Works collaboratively with department leadership, physicians, and staff to ensure exceptional delivery of care by continuously improving quality processes and standards. Works to ensure the delivery of high quality, developmentally appropriate patient and family-centered care in a cost-effective manner for patients at Driscoll Health System. Responsible for the continuous assessment and improvement of standardized quality of care delivered to patients through the assessment of all clinical outcomes.

Essential Duties and Responsibilities:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This job description is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by the immediate supervisor and/or hospital administration as required.

• Maintains utmost level of confidentiality at all times.
• Adheres to hospital policies and procedures.
• Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines. 
• Manages the coordination of the quality program of the assigned department(s).
• Conducts routine audits to ensure goals are met and action plans are maintained for quality improvement initiatives.
• Evaluates and monitors outcomes and processes to improve the quality of care in the assigned departments, including hospital-acquired conditions and adherence to prevention bundles.
• Participates in investigations of potential safety events including review of clinical documentation and interviews with involved staff.
• Collaborates with department leadership, physicians and staff to identify performance improvement opportunities aligned with system goals and strategic objectives.
• Facilitates creation of action plans to address metrics above or below benchmark, adverse events, safety events, and/or any quality improvement initiatives.
• Uses quality improvement science to facilitate multidisciplinary teams to achieve performance improvement goals and mentors team members on use of improvement methodologies.
• In collaboration with administrative and physician leaders, facilitates Quality meetings, including the development of agendas, presentations, meeting minutes, and additional resources needed. Maintains records for all performance improvement activities.
• Shares quality data and improvement projects with leadership and stakeholders in various forums.
• Serves as a liaison between the Quality office and department physicians and staff.
• Serves as resource and facilitates departmental adherence to accreditation requirements and Centers for Medicaid and Medicare Services (CMS) Conditions of Participation (COPs).   Collaborates with leadership team, physicians, and staff to implement policies, protocols, procedures, and processes to ensure compliance.
• Assists in preparing all documents and data necessary for verification and survey. Participates as the key liaison during any audits and obtains any additional information as necessary.
• Manages the coordination and oversight of department specific certifications, accreditations, designations or awards applications.
• Collaborates with Decision Support and other data analysts to ensure validation and accurate reporting of outcomes data to relevant benchmarking entity (e.g., VON, STS, PC4, etc.)
• Coordinates management across the continuum of children’s care, which includes planning and implementation of clinical protocols and practice management guidelines, monitoring care of hospital patients and serving as a resource for clinical practice.
• Promotes a culture of safety by modeling error prevention techniques and serving as a Zero Hero coach for assigned departments.

Education and/or Experience:

• Bachelor's degree from four-year College or university; or one to two years related experience and/or training; or equivalent combination of education and experience.
• 2 years’ experience in clinical area of position, Quality, or Regulatory experience
• Preferred: PDSA PI team experience

Certificates, Licenses, Registrations:

• Licensed in Texas if required for specialty i.e.: RN – Registered Nurse in Texas, Respiratory Therapist in Texas, etc.