Director, Quality & Patient Safety

UT Health East Texas is comprised of 10 hospitals, more than 90 clinics, the Olympic Plaza Tower, 13 regional rehabilitation facilities, two freestanding emergency centers, regional home health services covering 41 counties, an EMS fleet of more than 50 ambulances and four helicopters, and a comprehensive seven-trauma center care network, including the region's only Level 1 trauma facility. In 2024, we also added six Urgent Care clinics to our network. Our team includes nearly 400 employed providers and more than 7,000 team members.

As a partner with the University of Texas System, UT Health East Texas is uniquely positioned to provide East Texans with access to leading-edge research and clinical therapies while training and educating the next generation of providers and other health professionals. Graduate Medical Education is an integral component at UT Health East Texas. With Family Medicine, Internal Medicine, Occupational Medicine, and Psychiatry residency programs, we also welcomed our first class of medical students in 2023 in partnership with The University of Texas Health Science Center at Tyler.

In partnership with UT Health Science Center Tyler, Ardent Health Services operates UT Health East Texas system.

UT Health East Texas Rehabilitation Center:

UT Health East Texas Rehabilitation Center provides a large network of post-acute rehabilitation facilities to patients across the region. Over the past 25 years, our care network has grown to include a 49-bed inpatient hospital, 14 outpatient therapy clinics, 11 cardiopulmonary rehabilitation clinics and nine Olympic fitness centers. As part of the UT Health East Texas system, UT Health Rehabilitation Center has access to some of the most advanced therapy techniques and care available - including physical, occupational and speech therapies. We also offer cardiovascular and cardiopulmonary rehabilitation - with our Tyler center boasting the first intensive cardiac rehabilitation program in East Texas. At UT Health Rehabilitation Center, you'll find a team of caregivers dedicated to helping patients restore and maintain their independence.

POSITION SUMMARY

The Director, Quality and Patient Safety at UTHET is accountable for assisting the organization to improve quality, safety, and reduce operational risk exposure through performance improvement processes and meeting regulatory and accreditation requirements. They will assist in the implementation of UTHET's Quality/Clinical effectiveness function. This position supports a culture of high reliability and the measurement of care quality identifying opportunities and executing on strategies for performance improvement in the following areas of the organization:

• Outcomes - highly reliable processes, delivering exceptional outcomes and/or optimal health
• Safety - Deliver the safest care to patients driven through leadership and a culture of high reliability
• Accreditation-Ensures all regulatory requirements are managed and highly functional
• Experience of Care - relationship-centered care grounded in empathy, dignity, respect and collaboration

• Support a proactive, comprehensive strategic Quality agenda that inspires caregiver engagement, inter-professional collaboration, the identification and use of evidence-based practice and management among all entities in the system while differentiating UTHET as a high reliability organization nationally.
  • Provides accurate and meaningful data to teams, committees and physician groups by understanding data dictionaries and using appropriately, using self-coded data sheets, assisting in determining appropriate data to collect by asking right questions and identifying correct populations, and using working knowledge of existing databases to obtain data already being collected.
• Appropriate knowledge and application of basic statistical tools, such as, standard deviation, frequency distributions, histograms, and Pareto charts.
• Actively participate in divisional meetings, processes, and activities to ensure Quality functions are disseminated consistently throughout the division.
• Chair and lead the local Performance Improvement Committee.
• Acts as a liaison between the Performance Improvement Committee and the Governing Board, to ensure all CMS CoPs are met.
• Applies quality improvement methodologies as a quality representative/facilitator for PI Teams and as a consultant to provide basic CQI or statistical tools.
• Evaluates and makes recommendations for system improvements using quality data, event and regulatory compliance reports.
• Provides project management to assigned teams by providing leadership to focus areas and by utilizing facilitation and assessment skills to develop evidence-based initiatives.

Regulatory Compliance:

• Drives all regulatory functions on the local level.
• Applies a current working knowledge of regulatory compliance standards as appropriate to assignment or specialty.
• Participates in all divisional regulatory functions and standards.
• Leads the participation and management of the Internal Quality Survey process, including timely and appropriate response to action plans.
• Lead and drive the sustainability efforts for all IQS and TJC action plans to ensure compliance is maintained and practice changes are hardwired.
• Provides advanced consultation and support by collaborating with peers throughout the corporation to develop methods and plans to meet standards, participating in the writing or development of new policies, procedures and guidelines, researching literature and outside sources to identify new methods, technologies, or approaches for compliance, ensuring compliance to regulatory support and assessing compliance to standards to ensure a safe and consistent care environment to multiple areas and settings.

Patient Safety:

• Leads Mission Zero: Our Culture of Safety on the local level, based on division standards and expectations.
• Leads and/or functions as the Risk Manager on the local level, based on division standards and expectations.
• Applies a current working knowledge of national, local, and system patient safety standards and trends as appropriate to assignment or specialty.
• Leads PSEA and RCA efforts and reports to the Ardent PSO, per requirements.
• Participates in the division SENT process for reporting safety events.
• Participates in the division safety event classification process.
• Provides collaboration and consultative support to Risk Management, Compliance, Medical Staff, Nursing, and others by compiling reports with recommendations from appropriate sources, participating in maintenance of applicable Safety Plans, networking across departments and facilities to achieve objectives and goals, participate or facilitate patient safety improvement teams, and engages and interacts with staff at all levels to encourage ownership of initiatives.

Practice Standardization and Policies:

• Advocate and support standardization by educating focus areas to centrally developed policies, procedures, processes, and forms and assisting/participating in corporate teams with the development of policies, procedures, processes, and forms.
• Participate in development, implementation, revision, and review of policy, procedures, protocol, guidelines, and forms, when appropriate for focus areas.

Education:

• Provides education to focus areas regarding Quality Monitoring and Improvement, Regulatory Compliance, Patient Safety, Risk Management, Medical Staff Services and Practice Standardization and Policies. Informatics, Data and Analytics
• Support quality measurements for internal use.
• Support and distribute standardized reports that are developed centrally to ensure consistency in data management and reporting across the division.
• Support the deployment and optimization of the electronic health record to maximize safety, quality outcomes, clinical effectiveness and efficiency.
• Advance, with others, the use of predictive analytics and deep learning computing to improve the health, experience and quality of care of those we serve.

Supervision:

• Depending on the facility, the director may be responsible for 3-5 direct reports.

Education & Experience:

• Required: Bachelor's degree in Business, Healthcare Administration, Public Health or other business related field. Education must be obtained through an accredited institution and will be verified.
• Experience leading successful Quality Improvement projects.
• Experience with change management with the ability to provide leadership in the adaptation and implementation of new processes and /or technology that enhance Quality.
• Experience overseeing patient safety programs.
• Experience leading teams.

Certification and Licensure:

• One of the following certifications is preferred: CPHQ, CPXP, CPSP, CPHRM
• Trained in improvement science (i.e., Six Sigma, Lean, UT System CSE or DMAIC)
• Experience working in a complex health system (hospitals, ambulatory clinics, post-acute care, etc.)
• Experience with external entities that drive and support Quality approaches and standards, including government agencies, academic institutions, universities and related organizations of higher education, and other public institutions is preferred

Knowledge, Skills & Abilities:

• Effective verbal, written and interpersonal communication skills.