Director - Quality Management

  • HCA
  • Pasadena, TX, USA
  • Jan 11, 2018

Job Description

Job Code: 00009-88599


No Weekends

Bayshore Medical Center - Pasadena, TX

Director - Quality Management

Nestled in the heart of the historic land where Texas won its independence, Bayshore Medical Center offers comfort, convenience, excellence and expertise to our neighbors who trust their health care to us.

For nearly 50 years, we have offered patients solace and security through constant, compassionate communication during their medical emergencies, surgeries, and diagnostic procedures. As a 345-bed facility, we employ 1,500 staff and 250 physicians.

Bayshore Medical Center is currently looking for a Director - Quality Management.

  • Duties for this position included but are not limited to the following:
  • Promote a culture that is positive, that values individual strengths, takes risks, and is committed to optimal patient care, and compliance with regulatory standards.
  • Facilitate the growth of hospital knowledge regarding quality and high reliability, including the dissemination and implementation of "best practices" across the facility.
  • Support facility-wide standardization in targeted process improvement initiatives, and evaluate success through pre-established criteria and measurement tools. Support division-wide standardization of process improvement initiatives through facility adoption and implementation.
  • Assist with proactive patient safety activities to help create facilities that are high reliability organizations, as reflected in reduced errors, elimination of unsafe processes, and increased involvement of staff and physicians toward a culture of safety.
  • Performs regular analysis of facility quality and risk performance data, and plans steps based on data analysis for ongoing improvement.
  • Responsible for reporting of data to approved third parties, such as Leapfrog, NCDR & STS databases, etc.
  • Lead and/or support clinical process improvement teams as needed to achieve quality and performance improvement goals.
  • Collaborates with clinicians and other staff in developing and implementing processes to drive improvement and to comply with regulatory standards.
  • Responsible for the ongoing review, revision, and implementation and/or adoption of relevant policies and procedures, plans, and manuals as appropriate.
  • Serve as a regulatory resource (in addition to FVPQ) regarding state and federal regulations and standards, including but not limited to CMS, TJC, and CDC. Stay current with NQF, AHRQ, Leapfrog, IHI and other quality performance initiatives.
  • Executes special projects and other duties as assigned.

  • Master's Degree required
  • Current RN license in the State of Texas preferred
  • CPHQ required upon hire or within 12 months of hire
  • Five (5) years progressive experience in healthcare required.
  • Combination of three to five years of experience within quality, risk and/or patient safety required
  • Previous management experience required
  • Experience analyzing patient data and proved ability to implement actionable performance improvement plans required

Master's Degree

Last Edited: 01/09/2018