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Director of Quality Management - Baylor Rehab - Fort Worth 

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United StatesUnited States (US)
Health & Medical/Physiotherapist
Work Type:
Work Time:
Full Time


Director of Quality Management - Baylor Rehab - Fort Worth


Baylor Scott & White Institute for Rehabilitation

Fort Worth, TX


Director of Quality Management  (RN)


 Inpatient Rehab

42 Beds 



This a great opportunity to serve as a member of leadership as the Director of Quality at our Fort Worth hospital. This candidate must be a Registered Nurse. 


The Director of Quality 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 insure compliance with all regulatory and accrediting standards. Reviews clinical practice and works with staff to find the best strategies or solutions when concerns arise. Collects data to monitor compliance and/or trends.


1. Institutes and monitors the Hospital’s CQI Processes, utilizing data analysis measuring tools.  Assists in disseminating the organization’s Quality Management philosophies throughout the organization. Oversight/coordination of operations of the Infection Control & Employee Health Program based upon hospital size and configuration.

2. 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. 

3. Serves as a resource for all departments within the facility to provide guidance on designing, implementing, analyzing and reporting on Quality Improvement.

4. Assists clinical areas in developing criteria, monitoring and reporting mechanisms and action documentation related to the hospital’s CQI program.

5. Works with other hospital committees and departments to facilitate the incorporation of PI Processes into their CQI evaluation activities.

6. Facilitates quality assurance and Performance Improvement committee meetings (QUAPI).  Develops quarterly quality reports for governing body review.

7. 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.

8. Performs audits and reviews clinical documentation to determine regulatory compliance and opportunities for improvement. If remediation of a process is deemed necessary, strategizes with the interdisciplinary team to develop ways to facilitate improvement.  Communicates identified problems to the appropriate resources, department or committees for review.

9. Serves as consultant for all clinical PI indicators being implemented within the hospital. Provides PI facilitation skills to chartered PI projects assisting project team to meet their goals.  Coordinates and develops the dynamics of the team process, focusing in concurrent education of relevant PI tools.

10. Prepares analysis of significant PI findings pertaining to adverse drug reactions, drug usage evaluation, medical management of acute transfers and other CQI indicators.

11. Keeps informed of developments and trends in the field.

12. Serves as Coordinator of Clinical Quality Committee coordinating and assisting in performance improvement indicator(s), selection, management and statistical measurement.

13.  Assumes a leadership role in hospital RCA teams, working collaboratively with the interdisciplinary team in quality improvement activities.  


Minimum Skills, Knowledge & Abilities (including licensure, certification and other job-related



•Valid professional clincal license required in the work state. RN licensure required.

• Bachelor's degree required. Master's degree preferred

• Previous experience in Quality Improvement, with Statistical Process Control experience and computer skills preferred.

• Demonstrates familiarity with accrediting standards, including TJC and CARF preferred.

• Certified Professional in Healthcare Quality (CPHQ) preferred.

Additional Data:

Baylor Scott & White Institute for Rehabilitation, a joint venture between Baylor Scott & White Health and Select Medical, carries a well-known reputation for patient care and exceptional quality outcomes. We serve all people through exemplary healthcare, education, research and community service. Since opening in 1981, our flagship inpatient rehab hospital in Dallas has received repeated recognition by U.S. News & World Report as one of the best rehab hospitals in the nation.  All of our inpatient hospitals are accredited by The Joint Commission, including specialty accreditation for our stroke rehab programs. And for five consecutive years we have been recognized as a “Best Place to Work” by the Dallas Business Journal.

With the combined expertise of our joint venture partners, Baylor Scott & White Rehabilitation has become one of the most recognized and largest rehabilitation providers in the nation. We have continuously grown in size, scope and excellence across North Texas, and in the summer of 2018 our footprint has expanded to include new partners in Central Texas. With this expansion, we have more than 2,300 talented, caring and compassionate team members working in the following environments:

4 inpatient rehab hospitals (free-standing)

2 inpatient rehab units in Baylor Scott & White Health acute hospitals

9 acute therapy units in Baylor Scott & White Health acute hospitals

87 outpatient therapy locations (and growing)

A home health division covering all of North Texas

Select Medical is an organization that is passionate about safety for our patients and our team members. The Inpatient Rehabilitation Division conducts post-offer employment testing (POET) for a number of job titles including, but not limited to: 

Rehabilitation Assistant/Nursing Assistant


Physical, Occupational and Speech Therapy

Environmental Services

  POETS are completed as part of the onboarding process- to be completed before an employee’s first day of work.


Select Medical is an equal opportunity employer committed to dealing with employees in a nondiscriminatory manner and based on job-related qualifications and abilities. The Company will recruit, hire, train, and promote all persons without regard to race, color, sex, religion, national origin, veteran status, age (40 and over), marital status, disability or history of disability (except where physical or mental abilities are a bona fide occupational qualification) or any other protected status.