Director of Quality Services - Full Time


Under the CEO’s general supervision, the Director of Quality Services is given the necessary authority and responsibility to perform the duties of the Director of Quality Services. Acts as the Compliance and Privacy Liaison for the facility works in tandem with all departments’ directors to ensure facility-wide compliance in all areas.

  • Directs hospital-wide Performance Improvement activities.
  • Ensures monitoring, aggregation of data, and evaluation of mandatory monitoring completion.
  • Educates staff and physicians regarding the Performance Improvement program, processes, teams and findings.
  • Works in partnership with the PI physician to monitor physician performance improvement initiatives, competence and peer review.
  • Facilitates PI teams to improve hospital processes, patient outcomes and/or patient/hospital safety.
  • Serves as a resource regarding performance improvement, accrediting and regulatory and compliance issues.
  • Ensures investigation (intensive as indicated) of all incidents/occurrences/near misses/sentinel events occurs as indicated with action steps implemented as defined.
  • Aggregates and presents Performance Improvement data with proposed action plans, recommendations for improvement to appropriate leaders/groups.
  • Develops new avenues for facility growth.
  • Maintains mutually beneficial relations with physicians.
  • Coordinates continual hospital-wide compliance with DNV standards.
  • Assists leaders in department indicators and compliance activities.
  • Audits medical records to ensure compliance on designated criteria.
  • Prepares presentation reports with action plans and evaluations.
  • Ensures ongoing review of hospital practices in order to maintain hospital licensure and accreditation.
  • Reviews Incident Reports; monitors and tracks for potential trends or other possible problems/concerns.
  • Provides incident report/statistical analysis to the Executive Committee and Governing Board.
  • Ensures compliance with all regulatory agencies governing healthcare delivery and the accrediting bodies’ rules, staff committee meetings as assigned.
  • Attends and serves on professional/community organizations as a hospital representative.
  • Works with facility Safety Officer in implementing and maintaining programs for patient/employee safety.
  • Assists in ensuring staff remains in compliance with hospital and department policies and procedures.
  • Contributes to monthly staff meetings ensuring appropriate information is reported and communicated.
  • Coordinates and participates in development/maintenance and implementation of hospital fire, hazardous materials, disaster, utilities, security, medical equipment, evacuation plans.
  • Reviews and promptly acts on reports and recommendations from regulatory and inspecting agencies.
  • When appropriate, communicates operational concerns and needs to CEO.
  • Serves as hospital representative in its relationships with outside agencies and vendors.
  • Hospital Policies and Procedures: Consults with appropriate department heads to review and initiate organization-wide policies and procedures needed to accomplish the hospital’s goals, objectives, and programs.
  • Serves as hospital Compliance Liaison.
  • Consistently completes all required paperwork in a timely manner.
  • Performs other duties as assigned.
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Job Requirements


  • Experience in Performance Improvement/HIPAA/DNV/Risk Management.
  • Prefer experience in management with regards to supervising, managing, and working with a variety of people on an individual and group basis.
  • Extensive experience in compliance and conducting internal investigations.
  • Background in healthcare.

Education Required

  • Prefer B.S. in nursing or equivalent clinical background.
  • Continuing education in the area of nursing practice, patient safety, and quality.
  • Extensive knowledge in DNV standards, Medicare/Medicaid regulations.

Additional Information


  • Current licensure to practice as a Registered Nurse in the State of Texas; preferred
  • Current AHA/BLS