DIRECTOR QUALITY, INFECTION CONTROL, EMPLOYEE HEALTH & ED - DALLAS

OVERVIEW Advanced Dallas Hospital & Clinics is part of the Advanced Diagnostics Healthcare System, a physician-led organization that is intensely focused on patients and fully dedicated to providing the latest technologies and treatment methods.
With luxurious accommodations, elegant dining options and concierge-style service, your stay at Advanced Dallas Hospital & Clinics is designed to be as comfortable as it is healing.
In addition to highly trained specialists who provide an advanced level of care, everyone on staff is committed to treating you with exceptional courtesy and compassion.
We’ll do our best to ensure that you not only feel well but refreshed.
JOB SUMMARY Under the direction of the CEO and the leadership of the CNO the Director of Quality, Infection Control, Employee Health, and Education oversees Quality, Compliance, Accreditation and directs the overall planning, operational management, and outcomes of programs and activities designed to ensure the safe and compliant provision of patient care and services by Advanced Dallas Hospitals & Clinics.
This position provides leadership to and facilitation of the organization’s compliance with all related legal and accreditation requirements, credentialing and licensing, quality plan development and execution, identification of quality improvement opportunities to include incident reporting, root cause analysis and action planning, related education and training, reporting requirements, related Medical Staff committees and activities and the follow up of reported compliance concerns.
DUTIES AND RESPONSIBILITIES 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, operations and service quality.
Consults and collaborates with clinical and non-clinical teams for improvement on key performance indicators, design processes for new initiatives, services and other identified targets.
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 acquisition and maintenance of accreditation, certification, and licensure.
Under the leadership/approval of the CNO, manages the maintenance of annual Quality Plan, all quality metrics, data abstraction and related reporting.
Ensures participation in all publicly reported measures required by CMS.
Develops, maintains, implements and communicates policies & procedures to support compliance and quality.
Manages a comprehensive patient safety program ensuring timely facilitation of Root Cause Analysis, action planning, monitoring and follow-up.
Works with departments to investigate problems and concerns, respond to and address identified issues and analyze potential risks.
Reviews, investigates and analyzes 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.
Supports Safety Officer in environment of care related activities including monthly safety rounds.
Participates at all hospital-level medical staff meetings are held and the minutes reflect regulatory agency requirements.
Participates with the hospital CEO for maintenance of all required licenses and accreditation surveys.
Develops Education plans and collaborates activities to ensure ongoing education and training for Leaders, Staff, Board of Directors and other stakeholders.
Serves as an internal consultant and subject matter expert in the areas of regulatory, process improvement, performance monitoring and statistical analysis.
Directs and leads assigned staff members to include hiring, training and developing, managing performance.
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.
Maintains and protects confidentiality regarding all aspects of patient care, personnel, and strategic issues.
Adheres to Confidentiality Policy.
Maintains positive working relationships and fosters cooperative work environment.
Adheres to the hospital’s compliance program.
Displays honesty and mutual respect when communicating with peers and other departments.
Follows through on problems that may compromise effective job performance by using appropriate chain of command.
Adheres to safety practices and meets requirements of National Patient Safety Goals.
Maintains and reports all Infection Control responsibilities.
REQUIREMENTS RN Texas Lic.
, current Minimum 3 years us management experience required.
Minimum of five years in healthcare required.
Minimum three years’ combined experience in hospital quality, risk and/or patient safety.
BLS certification required.
CPHQ preferred.
EDUCATION Bachelor’s degree in healthcare or similar OR of 5 years related experience (in lieu of Bachelor’s Degree) CERTIFICATION, LICENSURE RN Texas Lic.
, current BLS certification required – American Heart Association CPHQ preferred.
KNOWLEDGE SKILLS & ABILITIES Comprehensive and current knowledge of hospital quality and compliance.
Strong collaboration and interpersonal relationship building skills.
Demonstrated competencies in critical thinking and leading the development and execution of project plans.
Effective communicator with solid oral and written communication skills.
Organizational, time management and prioritization abilities.
Competent in utilizing computer software programs.
BENEFITS At Advanced Dallas Hospital & Clinics, we offer a competitive benefits package for our team.
Benefits may include medical, dental, vision, HSA, paid time off, 401K, and additional voluntary options.
With a career at Advanced Dallas, you can expect complimentary breakfast and lunch and free parking.
We're dedicated to you and the advancement of your healthcare career.