About this role
About Us
Here at Baylor Scott & White Health we promote the well-being of all individuals, families, and communities. Baylor Scott and White is the largest not-for-profit healthcare system in Texas that empowers you to live well.
Our Core Values are
- We serve faithfully by doing what's right with a joyful heart.
- We never settle by constantly striving for better.
- We are in it together by supporting one another and those we serve.
- We make an impact by taking initiative and delivering exceptional experience.
Benefits
Our benefits are designed to help you live well no matter where you are on your journey. For full details on coverage and eligibility, visit the Baylor Scott & White Benefits Hub to explore our offerings, which may include:
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level.
Job Summary
Provides senior-level leadership, consultation, and expertise in quality improvement, patient safety, regulatory readiness, and high reliability principles to support Baylor Scott & White Health's commitment to delivering high-quality, safe patient care. Leads initiatives that improve clinical outcomes, reduce preventable harm, enhance compliance with regulatory and accreditation requirements, and foster a culture of safety across the organization. Collaborates with leaders, physicians, and interdisciplinary teams to drive performance improvement, oversee patient safety programs, and achieve strategic quality goals through data-driven decision-making and evidence-based practices.
Essential Functions
Quality Improvement Leadership
- Serves as a senior internal consultant for quality, patient safety, and performance improvement initiatives.
- Facilitates and coordinates multidisciplinary quality improvement teams, strategic planning sessions, committees, and workgroups.
- Leads medium- to large-scale improvement projects that support organizational priorities and strategic objectives.
- Develops, monitors, and evaluates quality indicators and performance measures using evidence-based methodologies.
- Utilizes quality improvement frameworks and analytical tools to identify opportunities for process redesign and sustained improvement.
- Prepares and communicates reports and dashboards to leaders, physicians, committees, and executive stakeholders.
Patient Safety Leadership
- Serves as the designated leader for patient safety initiatives and promotes a culture of Zero Preventable Harm.
- Oversees event reporting processes, adverse event reviews, near-miss analyses, and harm-reduction initiatives.
- Collaborates with leaders, managers, and risk management teams to ensure timely, thorough investigation and management of safety events.
- Supports implementation of action plans arising from adverse events, root cause analyses, and proactive risk assessments.
- Serves as a trusted resource for staff to report safety concerns and promotes a fair and consistent culture focused on learning and accountability.
- Leads and participates in Patient Safety and Zero Harm rounding activities.
Regulatory and Accreditation Readiness
- Collaborates in the development, interpretation, implementation, and oversight of policies, procedures, and standards supporting quality and patient safety.
- Ensures compliance with Joint Commission, CMS, Texas regulatory requirements, National Patient Safety Goals, and other applicable standards.
- Supports accreditation surveys, regulatory reviews, and performance improvement plans arising from findings.
- Monitors publicly reported and internal patient safety and quality metrics.
Safety and Quality Program Oversight
Provides leadership and oversight for programs including:
- Sepsis Improvement Program
- Hospital Acquired Conditions (HACs)
- Falls Prevention
- Pressure Injury Prevention
- Medication Safety
- Patient Safety Indicators (PSIs)
- Preventable Adverse Event Reduction
- Facility Quality and Patient Safety Dashboards
- Leapfrog and other external quality reporting
Education and Culture Development
- Coaches, mentors, and educates leaders, physicians, and staff regarding quality improvement, patient safety, regulatory compliance, and high reliability principles.
- Facilitates training on event reporting systems, improvement methodologies, and patient safety practices.
- Promotes adoption of evidence-based practices and organizational learning from safety events and improvement initiatives.
- Fosters multidisciplinary collaboration and engagement in quality and patient safety efforts.
Data Analytics and Performance Monitoring
- Analyzes quality, safety, operational, and regulatory data from internal and external sources.
- Develops dashboards, scorecards, audits, and measurement systems to evaluate effectiveness of improvement efforts.
- Applies statistical and performance improvement methodologies to identify trends, mitigate risks, and improve outcomes.
- Supports leadership in establishing priorities and action plans based on data insights
Key Success Factors
- Knowledge of healthcare quality improvement, patient safety, and high reliability principles.
- Advanced knowledge of Joint Commission, CMS, state regulatory requirements, and accreditation standards.
- Strong project management, facilitation, coaching, and change management skills.
- Expertise in adverse event investigation, root cause analysis, risk reduction, and systems thinking.
- Excellent analytical, communication, and stakeholder engagement skills.
- Ability to lead organizational change and influence leaders and clinicians across multiple departments.
- Proficiency with quality metrics, dashboards, benchmarking, and performance analytics.
Belonging Statement
We believe that all people should feel welcomed, valued and supported.
MINIMUM QUALIFICATIONS
Education
- Bachelor's degree required.
- Master's degree in healthcare administration, nursing, public health, quality, or related field preferred.
Experience
- Three years of experience.
- Experience in healthcare quality, patient safety, risk management, regulatory compliance, or performance improvement highly preferred.
Certification
- Licensed clinician or Registered Nurse required.
- CPHQ, CPPS, CPHRM, or equivalent role-appropriate certification required within two years of hire.