We are looking to add top talent to our Baptist Hospitals of Southeast Texas team.
Join us in performing Sacred Work!
Competitive benefits are offered including:
Matched Retirement Plan
Paid Time Off
Comprehensive Benefit Plan - Medical, Dental, Vision and Much More!
Bonus Potential
Summary/Objective
Under the general supervision of the Chief Nursing Officer, the Director of Quality Management is responsible for establishing, maintaining, implementing, and evaluating an interdisciplinary Hospital-wide Performance Improvement Program to ensure ongoing assessment of patient outcomes and patient care delivery systems according to established standards. The Director of Quality Management provides oversight of activities to ensure that all required elements of standard compliance pertaining to regulatory and voluntary agencies are consistently maintained.
Essential Job Duties
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Directs and manages functions necessary to assure regulatory and accreditation compliance and advises the Hospital and Board on these matters.
• Coordinates regulatory survey and reporting activities within the organization, which would include staff compliance with patient safety goals and compliance with CIHQ and CMS standards.
• Directs and manages hospital-wide QA/PI Program, Peer Review/Reappointment, and State and Federal required reporting.
• Directs and manages development of QA metrics and targets and monitors QA processes to ensure that the methods are followed.
• Responsible for monitoring, coordinating, and ensuring hospital policies are updated and in compliance with State, Federal, and governing body guidelines.
• Supervises Patient Advocacy/Complaint & Grievance Process. Develop a quality strategy to help drive excellence across the fabric of the hospital. Collaborate with cross-functional teams to deliver enterprise quality solutions.
Required Education and Experience
Minimum of a Bachelor's degree in Nursing (BSN)
3 - 5 years related experience
Required License/Certifications
Current RN License in the state of Texas
AAP/EEO Statement
Baptist Hospitals of Southeast Texas (BHSET) provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, BHSET complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.
Other Duties
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.
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