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Director of Quality Management

Regulatory Affairs Professionals Society

This is a Full-time position in Houston, TX posted April 22, 2021.

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The Director of Quality Management is responsible for coordination, development and evaluation of all outcome activities including Risk Management, Quality Improvement, Survey Readiness, and Patient Safety.

Director Of Quality Management
Advanced Diagnostics Hospitals & Clinics   Houston, Texas, United States


The Director of Quality Management is responsible for coordination, development and evaluation of all outcome activities including Risk Management, Quality Improvement, Survey Readiness, and Patient Safety.

Job Duties and Responsibilities
Manages the system-wide Quality program through data collection, aggregating and analyzing data, maintain policies and procedures and reporting results to the Organization Improvement Committee, Medical Executive Committee, and the Governing Board.

Organizes monthly interdisciplinary QAPI Team meetings with activities per QAPI Calendar.

Directs the efforts of performance improvement initiatives to ensure overall compliance with all regulatory standards including national, state, CMS, TJC, DMV and other agencies.

Coordinates all survey activities to assure that the facility maintains accreditation, certification, and licensure.

Keeps TJC annual self-assessment current and assures submission to TJC as required.

Facilitates the alignment between improvement initiatives and the organization’s strategic plan; directs the day-to-day execution of the strategies and tactics necessary to improve patient outcomes and results of the organization.

Works closely with clinical and non-clinical teams for improvement on key performance indicators, design processes for new initiatives, services and other targets identified by Advanced Diagnostics.

Serves as an internal consultant and subject matter expert in the areas of regulatory, process improvement, performance monitoring and statistical analysis.

Holds “in-services “and instructs the management team and department managers on the principles of continuous quality improvement, as needed.

Assists Medical Director and Quality Program Director with development and implementation of medical staff quality improvement.

Leads hospital team in the performance of RCA at least annually and for every high-level incident, unless otherwise indicated.

Leads team in completion of one proactive risk analysis per year.

Review, investigate and analyze incidents for risk and adverse event identification, loss prevention and claims management purposes, including both potential and actual patient injury. Recommend interventions to enhance safety and well-being of patients, staff, and the organization at large.

Coordinate activities relative to programs, policies, and practices that ensure that all departments are following federal, state, and local regulatory requirements.  Supports Safety Officer in EOC activities.

Participates in monthly safety rounds.

Demonstrates the spirit of the philosophy, mission, and values of the hospital through words and actions and implements them into departmental processes, programs, and the working environment.

Applies the principles and values of customer service and continuous quality improvement while performing day to day activities of the position.

Performs other duties as assigned.

Qualifications (Education, Experience and Certifications)
Education:  Bachelor’s Degree from an accredited nursing program preferred.

Certification, Licensure: Current licensure as a registered in the state of Texas.

Experience: CPHQ preferred. Minimum of five years in healthcare required.

A combination of three to five years of experience within quality, risk and/or patient safety plus previous management experience required.

KNOWLEDGE, Skills And Abilities

Strong critical thinking skills. Excellent organizational skills.

Excellent writing and composition skills.

Must type 50-60 wpm.

Excellent computer, word processing, database, and credentialing software skills. Current BLS certification.

Internal Number: 7999

About Advanced Diagnostics Healthcare

Advanced Diagnostics Healthcare System is an independent, physician-led and patient-centered organization of hospitals, clinics and diagnostic centers in Texas.

We are entirely focused on bringing you advanced, comprehensive care and a superior patient experience.

And we are an in-network provider with most insurance plans.

Welcome to a fresh vision of healthcare.Advanced Diagnostics Healthcare System was founded by physicians and continues to be physician-led.

This ensures that within ADHS’ hospitals, clinics, telemedicine and surgeons and physicians network, the patient comes first and the physician leads.

Regulatory Affairs Professionals Society (RAPS)
5635 Fishers Lane, Suite 400
Rockville, Maryland 20852

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