Director Quality, Patient Safety, and Risk

Texas Health Hospital Rockwall; Plano (TX); On-site; USD 120,000 - 160,000; Full time

Job summary

Texas Health Plano seeks a Director of Quality, Patient Safety and Risk to drive high-reliability culture, regulatory readiness, and continuous improvement. The role will lead accreditation processes, safety initiatives, and data-driven performance metrics across the hospital.

The candidate will oversee peer review, risk reduction actions, and collaboration with executives to implement KPI dashboards and action plans; strong communication and leadership are essential in this critical role.

Qualifications

• Bachelor's Degree in Clinical or Healthcare Administration required
• Master's Degree preferred

Responsibilities

• Oversee accreditation activities (TJC, Chest Pain & Stroke, Bariatric, etc.).
• Direct and support patient safety and performance improvement initiatives with KPI dashboards.
• Manage peer review processes and professional practice evaluations as required.
• Lead HR strategy to recruit, develop, and retain staff; mentor growth.
• Collaborate with leadership to implement comprehensive quality and safety management processes.
• Assist in investigations of sentinel events, near-misses, complaints, and risk events.

Skills

Leadership

Communication

Data analysis

Regulatory knowledge

Stakeholder collaboration

Education

Bachelor's degree

Master's degree preferred

Tools

Microsoft Office

Job description

Director Quality , Patient Safety , and Risk

Are you looking for a rewarding career with top-notch benefits?We are looking for a qualifiedManagerlike you to join our Texas Health family.

Position Highlights

• Work location: Texas Health Plano
• Core Work hours: Monday – Friday 8:00a -5:00p

Since 1991, Texas Health Presbyterian Hospital Plano has served the communities of Plano, Frisco, Carrollton, Addison, Richardson, and McKinney. As a 386-bed, full-service hospital, we're proud to deliver exceptional care to North Texans through advanced technology and a dedicated team.

We offer a range of specialties, including emergency medicine and trauma, cardiology, neurosurgery and spine care, orthopedics, women's services, adult and adolescent behavioral health, and critical care. Our hospital also provides comprehensive surgical services supported by leading technology and clinical expertise.

As we look to the future, a new patient tower under construction and major campus renovations underway will deliver even greater access to advanced care in neuroscience, heart and vascular services, digestive health, and an expanded Emergency Department.

Texas Health Plano is a Level II Trauma Facility and the only health care provider in Collin County with Level IV NICU and Level IV Maternal Facility designations. We are also a DNV-certified Comprehensive Stroke Center and Primary Heart Attack Center accredited by The Joint Commission in Hip and Knee Replacement.

We're proud to be a four-time Magnet-designated hospital and home to the DFW area's only AACN Beacon Gold adult intensive care unit. Our team members enjoy outstanding benefits, including an on-site childcare center designed to support working parents.

• an on-site childcare center designed to support working parents.

Position Summary

The Director of Quality, Patient Safety and Risk Management will serve as a resource for Texas Health Plano by offering value-added knowledge and expertise in improving outcomes and providing safe, timely, cost-effective, person-centered care.This position is responsible for sustaining a culture of high reliability, ongoing process improvement and continuous regulatory readiness to ensure the safety of our stakeholders.

Key Responsibilities

OPERATIONS: ACCREDITATION/CLINICAL CERTIFICATION - Oversight and facilitation of accreditation activities to include but not limited to: TJC, Chest Pain & Stroke certifications Bariatric certification, etc.
OPERATIONS: PI/PATIENT SAFETY - Direct and support processes and coordinate tactics that advance patient safety and performance improvement. Track, trend and monitor performance improvement outcomes and risk events. Work with other departments on hospital and system initiatives and support evidence-based best practices. Ensure annual completion of FMEA for the acute care and Seay Behavioral Health Center. Direct clinical outcomes program.
OPERATIONS: PEER REVIEW - Oversee and facilitate Medical Staff Peer Review, including Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE). Assist peer review physicians and division chiefs in preparing and presenting case reviews and completing follow-up activities based on peer review findings.
HUMAN RESOURCES: Develop and implement strategy to create and maintain a positive employee relations environment for departmental employees. Recruit, orient and retain excellent staff. Supervise departmental staff, developing standards of performance, evaluating performance and initiating or recommending personnel actions. Mentor job-related growth of staff.
LEADERSHIP: Plan and execute in collaboration with Chief Medical Officer, Chief Nurse Executive and Texas Health leadership the implementation of a comprehensive quality and safety management process. Develop and maintain KPI quality dashboard. Direct the preparation and maintenance of department reports and tracking of data for quality and safety initiatives, including preparation of reports for committees and top management as required. Monitor and supervise hospital compliance with The Joint Commission (TJC) and governmental agencies, standards and requirements, acting as liaison during site reviews. Participate in and represent THP in system-wide quality/patient safety committees and initiatives. Take initiative and coordinate with other departments to develop action plans for performance improvement and patient safety initiatives and risk reduction.
OPERATIONS: ASSIST IN INVESTIGATION/RESPONSE TO SENTINEL EVENTS/NEAR MISSES/COMPLAINTS/GRIEVANCES - Conduct initial investigation of events to begin information gathering process. Work with CQO/hospital staff/medical staff regarding management of event and communication with the patient/family. Communicate with the patient/family as necessary. Coordinate and facilitate RCA meetings and development of action plans. Monitor progress and effectiveness of RCA Action Plans. Work with Risk Manager to develop reports and results of action plans for Risk Management/Patient Safety Committee and Quality Integration Committee. Manage complaint/grievance process.
FISCAL RESPONSIBILITY: Assist in development of capital and operational budget and monitor compliance of same. Consider clinical, quality and operational outcomes and financial implications when making recommendation for changes in practices.

Education

Bachelor's Degree Clinical or Healthcare Administration Required
And
Master's Degree Preferred

Experience

7 Years clinical or in a hospital setting Required
and
5 Years progressive operational/program management experience Required
Managerial Experience Strongly Preferred
Quality Experience Preferred

Licenses and Certifications

Other Licensure as required by the state of Texas for applicable clinical discipline Upon Hire Required
And
CPHQ - Certified Professional in Healthcare Quality with in 2 Years of hire Required

Skills

Excellent verbal and written communication, negotiation and collaboration skills; ability to collect, analyze and organize data; team facilitation skills; knowledge of regulatory and accreditation requirements; ability to educate and motivate; able to use Microsoft Office applications

Why Texas Health?

At Texas Health Resources, our mission is “to improve the health of the people in the communities we serve”.

As part of the Texas Health family and its 28,000+ employees, we’re one of the largest employers in the Dallas Fort Worth area. Our career growth and professional development opportunities are top-notch and our benefits are equally outstanding. Come be a part of our exceptional team as we improve the health of the people in our communities every day. You belong here.

Learn more about our culture, benefits, and recent awards.