Administrative Director of Quality

HealthONE   •  

Austin, TX

Industry: Healthcare


Less than 5 years

Posted 98 days ago

This job is no longer available.

JOB SUMMARY (Primary purpose of the position.)

The Senior Director of Quality Management’s primary responsibilities are coordination of Regulatory, Quality (core measures/PI, Peer Review, HAC/SPAE), Infection Prevention, Patient Relations, Medical Staff/CME Services and Patient Safety initiatives across all campuses/enterprise. This role would have direct responsibility over Quality/Regulatory/Infection Prevention/Medical Staff Services/Patient Relations for all SDMC campuses.

Promotes performance improvement staff education and development.  Ensures appropriate and timely medical staff operations and activities including appropriateness and completeness of Medical Staff Bylaws, Rules, Regulations, Policies, and Procedures.  Ensures implementation and completeness of the Infection Prevention Program. Coordinates the needs of merger/acquisitions as it pertains to policies, integration into SDMC, and quality/regulatory. Would be the resource expert on all survey activities and would ensure sharing/coordination of best practices.  Would evaluate the need and manage the survey and disease applications process across campuses

GENERAL RESPONSIBILITIES  (The essential responsibilities and accountabilities of this position including interactions with other departments and outside vendors, if applicable, in PRIORITY order.)


  1. 1.     Implements and manages quality initiatives and activities throughout the facility including PI activities

a.     Performs annual quality and PI program evaluation and reporting.

b.     Develops, revises, and implements quality and PI plan.

c.     Serves as a quality resource to all facilities, departments, staff, etc.

d.     Coordinates quality and PI report cards, dashboard, and other reporting mechanisms across all facilities.

e.     Serves as member of selected facility and departmental PI committees, teams. Serves as Quality Facilitator/Leader of root cause analysis teams, (RCAs), FMEAs, etc.

f.      Analyzes and reports quality and PI indicators to the Quality Committees, Administration, and others as indicated. 

g.     Ensures compliance of corporate, regulatory, and accreditation requirements for quality, performance improvement, and patient safety across the enterprise. 

h.     Serves as representative to selected Partnership and other quality committees, initiatives, etc. 

i.      Coordinates quality activities with Quality Manager and other staff.

j.      Coordinates and guides physician peer review activities with the Quality Manager and Chief Medical Officer.

k.     Coordinates patient safety, national, corporate and other quality or patient safety initiatives.  Leads and facilitates designated initiatives throughout all facilities.

l.      Provides education to staff regarding quality and patient safety initiatives; promotes compliance and improvement.

2.     Essential Functions

a.     Manages resources between the facilities to ensure the patient receives the same standard of care at all campuses. This position could facilitate the sharing of resources in all areas that are part of the Quality department.

b.     Responsible for facilitating clinical process performance improvement activities in accordance with accreditation, regulatory and licensing requirements.  Coordinates facility-wide quality improvement (QI) programs, establishes standards of performance and provides assistance to the quality improvement teams.  Encourages development of staff through quality improvement in-service education, participation in Continuous Quality Improvement (CQI) training for employees and other programs.

c.     Provides support for the Quality Committees and other PI and peer review committees; assists with analysis of QI data; and supports and facilitates specific PI projects as needed.  Develops and implements policies, procedures and objectives and updates the Institutional Quality Improvement Plan as needed.

d.     Oversees compliance with TJC standards on a continuous basis throughout the hospitals and ambulatory settings, maintains TJC Periodic Performance Review (PPR) database and monitors TJC survey readiness plans.

e.     Represents the facility as a key contact in the coordination of TJC Core Measures and CMS Quality initiatives.  Maintains current working knowledge of TJC, NCAQ, CMS and other accreditation and regulatory standards applicable to hospital and physician office group practices.  Maintains current accessible copies of regulatory standards as a resource for staff.

3.     Manages departmental operations

a.     Ensures appropriate, timely, and professional communications.

b.     Develops and reviews department policies and procedures at least annually.

c.     Develops, implements and reviews goals, objectives and priorities, ensuring alignment with hospital strategic plans.

d.     Organizes departmental activities based on priorities, goals, objectives, and needs as arise.

e.     Assigns and adjusts staffing to meet priorities, goals, and objectives of department while ensuring smooth operations.

f.      Performs department human resource activities, e.g. staffing, competencies, training and skill checklists; annual and periodic performance evaluations; staff relations, staffing adjustments, etc.

g.     Ensures appropriate supplies and equipment are available to perform activities.

h.     Prepares and monitors budgets, productivity and other operational activities.

i.      Develops and implements department performance improvement (PI) plan and submits reports as required.

j.      Obtains and implements databases and other computer software to enhance department performance.

k.     Creates and analyzes a variety of reports as requested or needed.

l.      Conducts and records monthly department meetings with staff.

m.    Creates a work environment to promote optimum working conditions and employee morale.

n.     Maintains confidentiality.

o.     Performs other duties as assigned.

p.     Complies with all hospital policies and procedures, safety requirements, and emergency preparedness requirements.

4.     Oversees the management of and responsible for data analysis, collection and outcomes measures related to CHOIS, TMF, Core Measures, Q-Net, etc., and all elements related to the peer review process.

  1. a.     Maintains active knowledge regarding the above.
  2. 5.     Hires and directs staff in performance of duties.
    1. a.     Completes employee evaluations, high/middle/ low, rounding, time cards and other interactions in a timely manner.
    2. b.     Advises staff in decision making.
    3. c.     Adheres to all personnel and departmental policies.
  3. 6.     Establishes and maintains an adequate control over budget.
    1. a.     Submits an annual capital and operating budget.
    2. b.     Adheres to controllable budget projections and provides rationale for variances.
  4. 7.     Coordinates, compliance with Joint Commission, CMS, QRS and other regulatory bodies
    1. a.     Perform tracers throughout the facility and off-site locations on a routine basis
    2. b.     Educate the Medical Staff and hospital personnel regarding issues to maintain compliance
    3. c.     Assist the quality director in taking action on any issues identified during survey
    4. d.     Recommends actions to improve operational performance within the Medical Center.
    5. e.     Develops plans collaboratively to ensure the coordination of efforts to measure, assess and recommend actions for improvement.
    6. f.      Monitors progress of the improvement efforts and develops reports for the leadership of the organization.
    7. g.     Coordinates the synthesis of information on performance improvement.
  5. 8.     Manages the Infection Prevention Program
    1. a.     Perform tracers throughout the facility and off-site locations on a routine basis
    2. b.     Educate the Medical Staff and hospital personnel regarding issues to maintain compliance
    3. c.     Assist the quality director in taking action on any issues identified during survey
    4. d.     Recommends actions to improve operational performance within the Medical Center.

9.     Oversees the coordination, along with the Senior Patient Relations Representative, regarding issues involving the grievance and complaint process.

10.  Oversees the management of and responsible for processing and completeness of medical staff and allied health professional applications for appointment, reappointment, or privileges and compliance with professional requirements in accordance with Medical Staff Bylaws, Rules, and Regulations, and policies and procedures. 

11.  Oversees the management of and responsible for implementation of the facility-wide infection prevention, detection, surveillance and improvement system that includes education, tracking and reporting, process consultation, improvement and building a system wide infection prevention culture.

12.  All other duties as assigned.



Understanding of quality principles, theories and tools.  Data analysis and statistical background required.  Ability to perform computerized analyses and use data management, word processing, and presentation software as required.  Understanding of healthcare environment and strong project management skills are necessary for this position.  Understanding of clinical information, organizational behavior and group dynamics helpful.  Ability to interact effectively with a variety of professions and persons.  Comfortable and skilled at working with physicians, health care providers, and other stakeholders in the organization.  Effective written and verbal communication skills.  Ability to perform detailed, concentrated work with limited supervision.  Ability to identify issue and initiate improvements.  Must be able to demonstrate understanding of HCA’s and St. David’s “Patient’s First” safety initiative by strict compliance to all safety protocols and procedures.  

EXPERIENCE REQUIRED   (Minimum amount of specifically related experience which is required to perform the role at this level.

 3 - 7 years

Other required experience: 5-7 years experience in strategic planning, performance improvement in an organization to include implementing quality initiatives.  Healthcare experience required. Excellent people skills and presentation skills are required

Other preferred experience: Data analysis and statistical background a plus. Understanding human behavior and organizational behavior and organizational development knowledge is a plus


EDUCATION REQUIRED   (Minimum formal academic training which typically provides the knowledge

Bachelor’s Degree-Major: Nursing, Quality Management, or HealthCare Administration OR 10 years + experience in healthcare quality and patient safety

Education preferred: Master’s degree in healthcare, nursing, quality or business. Advanced training in Quality




Certified Professional in Healthcare Quality (CPHQ)

Required: obtain within two years

Bachelor's Degree

Job Code: 06676-62211