Assistant Director of Surgical Services Quality, Safety and Compliance

Assistant Director of Quality, Safety and Compliance

Surgical Services

WHY UT SOUTHWESTERN?
With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, innovation, teamwork, and compassion. As a world-renowned medical and research center, we strive to provide the best possible care, resources, and benefits for our valued employees. Ranked as the number 1 hospital in Dallas-Fort Worth according to U.S. News & World Report, we invest in you with opportunities for career growth and development to align with your future goals. Our highly competitive benefits package offers healthcare, PTO and paid holidays, on-site childcare, wage, merit increases and so much more. We invite you to be a part of the UT Southwestern team where you'll discover a culture of teamwork, professionalism, and a rewarding career!

BENEFITS
UT Southwestern is proud to offer a competitive and comprehensive benefits package to eligible employees. Our benefits are designed to support your overall wellbeing, and include:

• PPO medical plan, available day one at no cost for full-time employee-only coverage
• 100% coverage for preventive healthcare-no copay
• Paid Time Off, available day one
• Retirement Programs through the Teacher Retirement System of Texas (TRS)
• Paid Parental Leave Benefit
• Wellness programs
• Tuition Reimbursement
• Public Service Loan Forgiveness (PSLF) Qualified Employer
• Learn more about these and other UTSW employee benefits!

EXPERIENCE AND EDUCATION

Required

• Education
  Bachelor's Degree of Science degree in Business, Nursing, Medical Technology or related clinical science.
  

• Experience
  5 years of healthcare compliance, quality, and/or safety experience, and at least
  2 years of previous supervisory experience required.
  Working knowledge of process improvement techniques, electronic medical record functionality and data collection methodologies.
  Knowledge of state and federal regulatory standards.

  
  

  Licenses and Certifications
  If a RN, (NLC) NURSING LICENSURE COMPACT-BNE current Texas (or BNE Compact State) license

Preferred

• Education
  Master's Degree
  

• Licenses and Certifications
  (ASQ) AMERICAN SOCIETY FOR QUALITY Upon Hire or
  (CPHQ) Cert Pro in Hlthcr Quality Upon Hire or
  (ASQ MBB) MASTER BLACK BELT LEAN SIX SIG Lean Sigma Six Upon Hire
  

JOB DUTIES

• Assures Peri-Operative Services compliance with all applicable state and federal regulatory agencies. Supervise and direct Surgical Services quality analysts/safety coordinators.
• In collaboration with Peri-Operative Services and Office of Health System Quality, designs and updates Surgical Services Quality and Performance Improvement Plan annually.
• Monitors and reports on patient safety related incidents, identifies trends and initiates performance improvement initiatives.
• Facilitates implementation of best practice clinical process improvement initiatives to assure safe, high quality patient care. Provides expertise in data collection, reporting methodologies and ongoing monitoring to ensure sustained improvement in processes. Develop and monitor Peri-Operative Services patient quality initiatives and outcomes per the QAPI plan.
• Orchestrate multidisciplinary and interdisciplinary process improvement initiatives aligned with hospital and health system quality and patient safety goals. Collaborates with colleagues in the Office of Health System Quality to ensure flow of information, planning, and alignment with strategic direction.
• Report service line quality, safety, and regulatory compliance activities/status at health system and Service Line meetings, (PIC, Pharmacy Committee, TJC Chapter leaders, Hospital Safety Committee, Patient Readiness Committee, etc).
• Ensures accurate and timely data submission for national registries. Provides registry outcomes/performance reports to key stakeholders including Division Chiefs, Medical Directors, Administration, and appropriate Quality and Regulatory committees. Develops recommendations from these outcome reports and works with the team to develop action plans for improvement.
• Conducts monthly tracers to ensure compliance with regulatory standards on a monthly basis.
• Serves as a mentor to Clinical Safety and Effectiveness teams and Lean Six Sigma participants.
• Performs other duties as assigned.

SECURITY AND EEO STATEMENT

Security
This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information.

EEO
UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination, including discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status.