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Director of Quality Improvement and Patient Safety


Performance Improvement




Full Time


Minimum Entry Level Qualifications:

  • Academic Preparation: Bachelor of Nursing required and a current Texas R.N. license. Master degree preferred. Certified Professional in Healthcare Quality (CPHQ) preferred.
  • Experience and/or level of competency : At least 5 -7 years of relevant acute-care hospital experience in quality, patient safety, regulatory and accreditation, and performance improvement.

Job Summary:

The Director of Quality Improvement and Patient Safety provides operational and strategic leadership to support VVRMC mission of delivering healthcare the community can trust The Director works collaboratively with senior leadership, physicians, risk management, nursing, pharmacy, and leadership to develop and implement a best-in-class hospital’s quality and safety program and to ensure regulatory compliance and accreditation. Works closely with the Chief Medical Officer to develop, monitor, and educate others on the use of patient data systems that drive improvement and reporting of patient outcomes through the use of evidence-based data and scorecards.

Specific Responsibilities:

  • Collaborates with hospital and physician organization leaders to envision, develop, and implement the organization’s quality and patient safety plan.
  • Coordinate the process of monitoring, measuring, and assessment of patient care and support of systems to achieve high quality, safe, cost effective healthcare services.
  • Coordinate and oversee hospital Quality Improvement Plan development, review, revision, and implementation.
  • Coordinate and integrate QI plans and processes for individual services.
  • Oversees the direct operations of the QI/PS department and its staff and budget.
  • Organizes, coordinates and attends all hospital, board quality, and Medical Staff committee meetings and participates in all pertinent hospital committee meetings where monitoring functions and activities are performed.
  • Serve as a resource for Medical Staff and internal services on quality improvement activities, education, and use of quality principles and tools.
  • Facilitates, develops, and implement special projects as assigned by the CNO and CMO.
  • Oversees regulatory readiness, quality measurement, public reporting, and pay-for-performance programs and initiatives, holding staff and departments accountable for achieving performance goals.
  • Establishes quality measurement and improvement activities, including methods to track implementation of action plans following site surveys and critical events reviews.
  • Oversees reporting and communication of quality improvement initiatives, quality and patient safety awareness, safety culture survey administration, and recognition programs.
  • Coordinates and reports Medical Staff Quality Assurance/Improvement activities.
  • Coordinates and manages Core Measures reporting and other functions.
  • Collects and reports HCAHPS data for the facility functions.
  • Facilitate CQI teams as requested. Facilitate planning sessions as requested.
  • Collaborates with hospital Director of Infection Control and Director of Risk Management.
  • Teaches quality and patient safety concepts to clinicians, trainees, and other staff during orientation and in various educational settings.
  • Leads the root cause analyses and failure modes and effects analyses and debriefings.
  • Coordinates closely with clinical information technology and health information management to achieve organizational goals.
  • Promotes a culture of safety, high-reliability, patient and staff engagement, and performance excellence.
  • Develops, evaluates, and maintains quality dashboards and performance metrics.
  • Supports and mentors employees of the department and other staff, students, and trainees with interest in quality and patient safety.
  • Maintains current competency and expertise in quality and patient safety.
  • Performs other duties as assigned.

Standards & Expectations:

  • Personal Behavior: The Mission/Vision/Legacy (MVL) Statement and Core Values defines the culture of VVRMC and each employee is expected live MVL and adhere to the behaviors defined in the six (6) Core Values. This agreement is reinforced annually. All employees are to understand and actively support MVL and the Core Values. Managers are expected to be active role models and intervene when appropriate. Attached as a part of this job description is a copy of the MVL and Core Values.
  • Compliance to Regulatory and/or Administrative Rule: VVRMC is a County Hospital District operating in compliance with the rules, regulations, and policies established by Federal, State, County and hospital authorities. Employees and manager are expected to understand the limitations of their role and responsibilities and to act within their scope of work. Each is expected to ask for assistance from competent leadership when in doubt.
  • Job Competency: All positions in the hospital require competency assessments each year. Each employee and manager is expected to satisfactorily complete the appropriate testing and/or assessment required within the time frame established.