Director of Quality (FT-EXEMPT)

Full Time
Main Hospital Campus in Bay City, Texas
Posted 3 months ago


The Director of Quality and Patient Safety provides strategic direction, advancement and management of Matagorda Regional Medical Center’s (MRMC) quality and patient safety programs. The Director works in partnership with hospital staff, leadership and medical staff to develop and implement a successful quality plan and to ensure regulatory compliance and accreditation.

Initiates and oversees the development of a comprehensive Quality/Performance Improvement Program. Engages Medical Directors and staff in quality work to develop Medical Staff and System Leadership. Directs and coordinates Quality/Performance Improvement Initiatives for MRMC. In collaboration with Clinical Staff and Services Chiefs, participates in the development, monitoring, reporting, and improvement of activities related to Clinical Pathways and Guidelines. Fosters and maintains collaborative relationships with external agencies, purchasers, and stakeholders related to quality/performance initiatives.

 Initiates, oversees, and integrates a comprehensive Medical Safety Program as a component to MRMC’s Quality Services to ensure a “Culture of Safety” for patients, visitors, and employees. Recommends PI activities related to Medical Safety.

Coordination and oversight of data collection and analysis, management, submission, and presentation for Quality Improvement and management of MRMC Performance Improvement Plan. This includes the reporting and presentation to the Quality Improvement Council, Administrative and Managerial Meetings, various Medical Staff Committee meetings, , Medical Executive Committee and Board of Managers.

Reviews and evaluates services of MRMC that are affected by Medical Safety issues, identifies problems, makes recommendations for improvement, and monitors services to ensure that safety recommendations are implemented and the desired results are obtained. Proactively educates MRMC Leadership and Medical Staff regarding safety issues, new statutes/guidelines, and Medical Safety/PI activities. Regularly communicates PI and Medical Safety activities to the Medical Staff and engages Medical Staff in PI activities. Serves as a resource within MRMC for Medical Safety and PI issues. Participates in various Medical Staff and Hospital Committee meetings and the Quality Improvement Council to establish PI priorities. Leads the development of MRMC’s policies and procedures related to Quality Improvement and Medical Safety and participates as a stakeholder in the development of MRMC’s policies and procedures.

Ensures the development of policies and secures MRMC’s approval. Sets system policy for organizational structure and collaborates in the approval of proposed structures. Development of long-range goals, annual objectives, and strategies for area(s) of responsibility. Measures and reviews systems performance. Develops and, as appropriate, seeks approval of system budget. Reviews budget performance. Provides input into major capital expenses related to quality.


  • Identifies, develops and implements objectives relative to the Quality and Process Improvement area as it relates to MRMC’s Strategic and Operational Business Plan.
  • Works in conjunction with the Medical Staff and Nursing to derive useful, valid, and reliable data to guide and improve quality of care. This includes responsibility for the Quality Reports, Performance Improvement Projects, and coordination of participation in external projects related to outcome measurements and Quality Initiatives.
  • Apprises the Medical Staff, Quality Improvement Council, and Senior Leadership of trends, significant events, and potential issues.
  • Leads the development, implementation, and continued support of the Quality Improvement Council.
  • Responsible for the continuous improvement and achievement of the goals in all areas of Value Based Purchasing across the organization.
  • Assures continued compliance with The Joint Commission, State, Federal and other regulatory agencies.
  • Development of Department Staff through on-going coaching, in-service education, on-the-job training and evaluation.
  • Provides oversight and direction of multiple PI projects and communicates results to keep leadership informed of the initiative and recognize success.
  • Consistently utilizes data and available resources to identify and stay current with trends.
  • Responsible for coordinating the Ongoing Professional Practice Evaluation reports and data for each practitioner credentialed through the medical staff process.
  • Develop and foster effective collaboration between clinical departments and divisions to ensure an integrated approach to quality, safety, and performance improvement.
  • Develop new strategic and tactical plans for the improvement of quality and patient safety. This includes analysis of quality and financial data and continual culture improvement.


  • Bachelor’s Degree in Nursing or other clinical discipline required.
  • 5+ years progressive experience in a hospital or similar healthcare setting required; 3+ years experience in quality role preferred
  • Demonstrated knowledge of quality and process improvement systems and methodology
  • Certification in Professional Healthcare Quality (CPHQ) preferred


  • Candidates will have at least five years of progressive experience in a healthcare institution. A minimum of three years of experience in Quality Improvement Experience in earning the respect of physicians and other clinicians and being seen by them as credible in the Quality Improvement/Process Improvement area is critical.
  • Experience with improving clinical performance and using Quality Improvement principals to improve clinical outcomes.
  • Must be comfortable with presenting information in Medical Staff Committee Meetings, hospital PI Committees/Team Meetings, Administrative Meetings, as well as Board Meetings.
  • Must possess a working knowledge of PI tools and analytical techniques, basic statistical analysis, the Agency for Healthcare and Research Quality and Safety Indicators, the National Quality Forum Serious reportable events and Safe Practices, Institute for Healthcare Improvement Initiatives and multiple quality databases.

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