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Serves as the expert for Performance Improvement, Accreditation, and the Patient Safety program. Responsibilities include oversight for regulatory compliance related to Hospital Quality Reporting and regulatory submissions to CMS, (mortality reduction, readmission reduction, safety of care, complications) as well as leadership over the patient safety programs (Variance Reporting System, event investigation, mortality
review, and investigations and responses to outside entities as required). Organizes and leads accreditation preparedness and surveys. Provides input, through data and analysis to strategic decisions that affect patient safety. Works collaboratively with organizational leaders and medical staff to identify and address factors that may contribute to adverse patient outcomes or harm. Through the work of the Performance Improvement Committee, implements the organization’s quality and patient safety plan and serves as a catalyst within the system to move the organization forward; supporting a strong patient safety culture and high reliability processes.


Reports to
Senior Vice President Quality and PI

Job Specific Responsibilities
Healthcare Reform
• Responsible for providing leadership and coordination of external benchmarking, clinical database and registry activities related to outcomes data collection,
• validation, aggregation and reporting to meet hospital, quality improvement initiatives
• Serve as the expert resource on CMS Affordable Care Act Programs specific to Hospitals (IQR,
• OQR, eCQM, Hospital Value Based Program (HVBP), Hospital Readmission Reduction Program
• (HRRP), Hospital Acquired Condition Reduction Program (HACRP) and applicable State
• requirements,
• Keeps abreast of regulatory requirements, professional standards and competitive industry
• practices, as well as organizational initiatives with potential to impact current strategies.
• Provides program oversight for hospital quality measures. Ensures that all quality data submissions for regulatory agency deadlines are completed in a timely and accurate manner.
• Provides ongoing dissemination and assessment of performance and clinical outcome data to identify improvement opportunities and/or trends through aggregation and summation of data.
• Identifies quality improvement opportunities through analysis of facility and external benchmark data.
• Develops, evaluates, and maintains quality dashboards and performance metrics.
• Supports the work of the ACO/CIN through the Hospital Quality and Efficiency Program (HQEP) and the PI Committee.
• Coordinate and oversee the hospital Quality Improvement Plan (review, revision, and implementation).

Accreditation
• Lead accreditation readiness and compliance activities by overseeing organizational adherence to regulatory and accreditation standards, coordinating surveys, and ensuring continuous survey preparedness across all hospital departments.
• Monitor and evaluate compliance performance through audits, tracers, mock surveys, and data analysis; identify gaps, implement corrective action plans, and track sustainable improvement.
• Partner with clinical and operational leaders to interpret standards, implement evidence-based practices, and integrate accreditation, designation and verification requirements into daily operations and quality improvement initiatives.
• Provide education and guidance to leaders and staff on accreditation, designation and verification standards, regulatory updates, documentation requirements, and compliance expectations to support a culture of continuous readiness and patient safety.



Patients Safety
• Proactively engages with individual staff, teams, and services to improve safety, quality and efficiency of care. Utilizes a wide range of analytical and evaluative methods and techniques in providing consultation regarding HRO and patient safety that supports the mission, vision, values, strategic plan and organizational priorities.
• Lead organizational patient safety initiatives to reduce medical errors and preventable harm through data-driven improvement, variance reporting, and continuous monitoring of progress toward zero avoidable harm.
• Promote a culture of safety and learning by sharing lessons from patient events, participating in PSO collaborations, implementing best practices, and providing ongoing education on high reliability and patient safety principles.
• Drive sustainable performance improvement through process evaluation, internal audits, accountability measures, and implementation of corrective actions that strengthen systems and improve patient outcomes.
Lean and Six Sigma / Continuous Process improvement
• Continually grow and adapt the quality improvement methodology to drive a wide variety of hospital initiatives across the organization.
• Oversees Lean Daily Management.
• Coordinate with hospital leadership to identify potential projects where continuous quality improvement can significantly improve efficiency, patient throughput, profitability, and customer satisfaction.
• Analyzes data to identify and recommend new processes, procedures and improvements.
• Continually seek innovative methods to manage and/or display data to drive performance improvement activities.
Medical Staff Engagement
• Promotes a successful working relationship with TTUHSC, UMCP and private physicians and staff. This includes, although not limited to:
• Collaborates with the Medical Staff Office to ensure correct OPPE data is available and reviewed as required for credentialing/re-credentialing processes as well as maintains current physician performance profiles for the reappointment process.
• Working with the CMO, gathers and analyzes clinical information from a variety of internal and external sources relating to patient safety, utilization of resources, physician practice patterns, system problems, and other quality functions.
• Has oversight of the Performance Improvement Committee, providing data and education to achieve sustainable improvements.
UMC Policy and Procedure Platform
• Manages the Document Management System, ensuring all
• policies and procedure within the organization maintain compliance with regulatory standards.
Coordination of Hospital Required Committees-
• Direct oversight in the management of the Professional Staff and other hospital required committees is maintained from scheduling to record retention.
Other
• Effectively manage financial resources within the area(s) of responsibility including labor management, productivity, supplies, and other resources.
• Interview, hire, orient and supervise employees, fostering a collaborative approach within the department for task/project completion, facilitating complaint resolution, implementing disciplinary procedures when needed, providing feedback to staff in a timely manner.
• Provide timely performance evaluations, budget reports and other responses as directed by the VP Quality and or CMO; attend required meetings, presentations or in-services and provide information to staff regarding Corporate plans.



Education and Experience
• Master’s Degree in Business Administration, Healthcare Administration, Nursing (with current licensure as a Registered Nurse in the State of Texas) or other clinically related filed required.
• Minimum of five (5) Five years’ healthcare experience in patient safety, risk, and/or quality in an acute care hospital setting with Knowledge of and experience with patient safety analysis techniques (SEA, PDCA, Lean Six Sigma, FMEA, etc.). Experience developing and implementing clinical, service and operational process improvement initiatives, both small and large scale.

Required Licensures/Certifications/Registrations
• Nurse applicants must be graduates of an accredited school of nursing and hold a current Texas nursing license.
• Certified Professional in Healthcare Quality (CPHQ), or Healthcare Quality and Management Certification (HCQM), within 2 years of employment is required. Six Sigma Certification preferred.

Knowledge, Skills and Abilities.
• Leadership - Well organized with the ability to handle various tasks simultaneously including the ability to prioritize, plan and execute without close supervision Initiative and ability to work independently (self-directed), while thriving in a setting requiring collaboration and teamwork for maximal efficiency and effectiveness. Strong organizational skills, with the ability to focus detailed concentrated effort to multiple projects and re-establish priorities as necessary. Actively leads through strong relationships and influence, holds others accountable. Collaborates, leads, coaches and engages staff at all levels in organization.
• Language - Ability to effectively present verbal and/or written information, including public presentations, as well as respond to the most sensitive inquiries or complaints.
• Mathematical- Ability to apply mathematical concepts such as fractions, percentages, rates and proportions to practical situations. Create and interpret various charts and graphs to present in understandable format.
• Reasoning - Ability to define problems, collect data, establish facts, and draw valid conclusions.
• Information Management and System s- This job requires computer and systems competency in the following areas: Enters data, retrieves data, assembles and organizes data, uses and analyzes data. Integrates diverse sources of data, including maintaining statistical reports.
• Mastery of desktop applications, including MS Office (Word, PowerPoint, Excel, VISIO)

Interaction with Other Departments and Other Relationships
Engages with clinical, operational, and support teams across the organization to advance patient safety and to provide best practices and strategies to support reliable, safe, high value care.

Physical Capabilities
Work is of light demand; frequent walking and prolonged periods of sitting. Lifting requirements of 20 pounds less than 10% of the time. Frequent computer work with computer competency.

Environmental/Working Conditions
This position is subject to inside environmental conditions. Protection from weather conditions is present, however, temperature changes inside the building may occur. Hours may vary to meet specific deadlines.

UMC Health System provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment on the basis of race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

*Request for accommodations in the hire process should be directed to UMC Human Resources.​*