Director of Quality Management - Inpatient Rehab
Baylor Scott & White Institute for Rehabilitation
Director of Quality Management (DQM)
Coordinates the Medical Quality Management and Performance Improvement activities to measurably enhance the quality, process and cost effectiveness of patient and customer services rendered. Coordinates the Performance Improvement and Patient Safety programs in accordance with the guidelines and regulatory requirements of Federal and State regulations on a hospital-wide basis. Oversees operations of the Infection Control and Employee Health Programs. Develops and Reviews policies and procedures to ensure compliance with all regulatory and accrediting standards. Collects data to monitor compliance and/or trends.
- Institutes and monitors the Hospital’s CQI Processes, utilizing data analysis measuring tools. Oversight/coordination of operations of the Infection Control & Employee Health Program based upon hospital size and configuration.
- Assists with the design and compliance of quality processes/activities in the areas of clinical/medical staff PI for all applicable clinical/medical TJC /CARF/DOH standards. Assists with all assigned activities to assure that the hospital maintains accreditation, certification and licensure. Assumes leadership with the Joint Commission and DOH as well as other regulatory agencies with regard to CQI activities.
- Serves as a resource for all departments within the facility to provide guidance on designing, implementing, analyzing and reporting on Quality Improvement.
- Assists clinical areas in developing criteria, monitoring and reporting mechanisms and action documentation related to the hospital’s CQI program.
- Performs basic chart review activities with appropriate staff for outcome utilization, infection control and medical CQI indicators. Analyzes results of chart review activities with appropriate staff and confers with department staff on any case requiring special attention.
- Prepares analysis of significant PI findings pertaining to adverse drug reactions, drug usage evaluation, medical management of acute transfers and other CQI indicators.
- Requires experience in at least one of the core areas of responsibility: Quality, Survey Readiness, Risk Management, Infection Control, Employee Health and Education.
- Current state licensure as a Registered Nurse required
- Bilingual (English/Spanish)
- Previous experience in Quality Improvement, with Statistical Process Control experience and computer skills preferred.
- Demonstrates familiarity with accrediting standards, including JCAHO and CARF preferred.
- Certified Professional in Healthcare Quality (CPHQ) preferred
Select Medical’s Inpatient Rehabilitation Hospitals provide advanced treatment and comprehensive care to best address the medical, physical, emotional and vocational challenges for individuals with:
- Brain Injury
- Spinal Cord Injury
- Neurological Disorders
- Orthopedic Conditions
- Multiple Traumas
**Select Medical is committed to having a workforce that reflects diversity at all levels and is an equal opportunity employer. Qualified applicants are considered for employment, and employees are treated during employment without regard to race, color, religion, national origin, citizenship, age, sex, sexual orientation, gender identity, marital status, ancestry, physical or mental disability, veteran status, or any other characteristic protected under applicable law.
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