Director of Quality and Incident Management

Join the Texas Health and Human Services Commission (HHSC) and be part of a team committed to creating a positive impact in the lives of fellow Texans. At HHSC, your contributions matter, and we support you at each stage of your life and work journey. Our comprehensive benefits package includes 100% paid employee health insurance for full-time eligible employees, a defined benefit pension plan, generous time off benefits, numerous opportunities for career advancement and more. Explore more details on the Benefits of Working at HHS webpage.

Would you thrive in an environment where you learn and grow personally and professionally all while helping make a positive impact on people’s lives? Do you appreciate being around others like yourself who are dependable, trustworthy, hard workers who believe in the value of teamwork? HSCS is dedicated to building an atmosphere where employees feel valued and supported while providing specialized care for Texans in need. HSCS is comprised of nine psychiatric hospitals, one youth residential treatment facility, and thirteen state supported living centers. The psychiatric hospitals are a hub of excellence for forensic mental health and complex psychiatric care, with all facilities accredited by The Joint Commission. They provide state-of-the-art treatment that is recovery-oriented and science-based. If providing hope and healing through compassionate, innovative, and individualized care interests you, we welcome your application for the position below.

Under the direction of the Director of Operations, the Director of Quality and Incident Management performs complex (senior level) managerial work leading of quality management, quality control, quality improvement, life safety, compliance, incident management, patient safety, and patient rights within the Texas State Hospitals (SHs). These service improvement initiatives include working with Center for Medicaid Services (CMS), the Joint Commission (JC), Office of Investigator General (OIG), Privacy Office, Department of Justice (DOJ) and other regulatory or investigative entities. The Director performs oversight and management of the Governing Body process and approvals, policy changes and special projects as outlined within strategic plans. The Director works closely with central office leadership, facility leadership and agency legal staff to ensure regulatory requirements and compliance are met with all state and federal laws and rules, and continuous improvement efforts are in place. Serves as a resource on SH initiatives to various internal and external stakeholders.

Performs other duties as assigned. Other duties as assigned include actively participating and/or serving in a supporting role to meet the agency’s obligations for disaster response and/or recovery or Continuity of Operations (COOP) activation. Such participation may require an alternate shift pattern assignment and/or location.

This position is telework eligible. Please note, all HHS positions are subject to state and agency telework policies in addition to the discretion of the direct supervisor and business need.

Essential Job Functions (EJFs):

Attends work on a regular basis and may be asked to work a specific shift schedule or, at times, even a rotating schedule, extended shift and/or overtime in accordance with agency leave policy and performs other duties as assigned.

Performs complex managerial work leading quality management, quality control, quality improvement, life safety, compliance, incident management, patient safety, and patient rights within the Texas State Hospitals (SHs), which includes working with regulatory and investigative entities. 20%

Prepares for and coordinates with SHs for participation in regulatory surveys, including Joint Commission surveys, to ensure compliance with healthcare standards. Ensure that all regulatory standards are consistently met and maintains up-to-date knowledge of accreditation processes and regulatory changes. Prepares reports for central office leadership and facility leadership regarding quality management, safety, and incident management performance. 10%

Monitors performance metrics related to patient care quality, satisfaction, and outcomes. Leads efforts to identify and address gaps or deficiencies within SHs. Works collaboratively with division, facility, and department leaders to develop, implement, and monitor quality improvement initiatives to drive continuous improvement. Utilizing best practices, provides direction and guidance in the development of policies, procedures, and protocols to standardize care across the SHs and the development of monitoring tools utilizing complex trend analysis resulting from the evaluation of SH program activities. 10%

Leads the establishment and execution of continuous quality improvement programs across the SHs. Conducts regular quality reviews, audits, and evaluations of patient care processes, identifying areas for opportunity and corrective actions. Fosters a culture of quality by training and mentoring staff on best practices for quality control and continuous improvement. 10%

Champions patient safety initiatives across the SHs, ensuring safety protocols and best practices are adhered to. Investigates and analyzes patient safety events, working with interdisciplinary teams to identify root causes and implement corrective actions. Leads efforts to develop and implement strategies to prevent safety incidents and minimize patient risk. 10%

Oversees the management and coordination of all incident reporting. Ensures that root cause analyses (RCAs) are conducted, corrective actions are developed, and follow-up is performed to ensure resolution. Collaborates with central office leadership, facility leadership, quality management directors, risk management, legal and others to ensure timely reporting and compliance with regulatory requirements or central office initiatives. 10%

Monitors and ensure that patient rights are upheld in all clinical interactions and that the organization complies with relevant patient rights regulations. Responds to concerns regarding patient rights, advocating for patients and working with clinical and recovery teams to assist patient rights officers in resolving issues swiftly. 10%

Provides leadership to the quality management and incident management teams within SHs, ensuring clear communication, accountability, and high standards of performance. Fosters an environment of collaboration and continuous learning through training, mentoring, and professional development opportunities. Conducts performance evaluations, provides feedback, and supports the professional growth of team members. 5%

Provides education and coaching of staff and SHs in the areas of expertise as described in this job description. 5%

Represents the agency at meetings with internal and external stakeholders, and establishes and maintains effective working relationships with stakeholders including patient family members, advocacy groups, professional organizations, other agencies, and the general public. Approves policies, procedures and special project activities, develops legislative appropriation requests and reviews and approves budget requests. 5%

Performs other duties as assigned. Other duties as assigned include but are not limited to actively participating and/or serving in a supporting role to meet the agency’s obligations for disaster response and/or recovery or Continuity of Operations (COOP) activation. Such participation may require an alternate shift pattern assignment and/or location. 5%

Knowledge, Skills and Abilities (KSAs):

Knowledge in working with large organization serving people with mental illness.

Knowledge of quality management principles, methodologies, data analysis methods and performance improvement tools.

Knowledge of patient safety, risk management, incident investigation procedures, and root cause analysis.

Knowledge of accreditation bodies (e.g., The Joint Commission, CMS) and standards, agency rules, regulatory standards, and other relevant operational laws, rules and regulations.

Skills with the ability to motivate and guide teams towards achieving common goals, including within central office and across the SHs.

Communication and interpersonal skills, with the ability to collaborate across departments and with external stakeholders.

Analytical skills to assess complex data, identify trends, and formulate effective strategies for quality improvement.

Ability to manage multiple priorities and projects simultaneously.

Ability to monitor implementation of and evaluate the effectiveness of management plans, corrective action plans, operational improvement plans and strategic plans.

Ability to work effectively in a dynamic and fast-paced environment and to make critical decisions under pressure, balancing risk and patient safety.

Strong problem-solving skills with the ability to think critically and strategically.

Ability to develop and deliver clear, actionable data driven reports to leadership and regulatory agencies utilizing evidence-based practices.

Ability to maintain a high level of professionalism, confidentiality, and ethical standards.

Registrations, Licensure Requirements or Certifications:

None

Initial Screening Criteria:

Bachelor’s degree in Quality Management, Quality Assurance, Business Administration, Healthcare Administration, Nursing, Public Health, Social Services, or a related field. A Master's degree is preferred.

Minimum of 5 years of experience in quality management, patient safety, or incident management, with at least 2 years in a leadership role.

Experience with Joint Commission survey preparation and regulatory compliance, including root cause analysis.

Additional Information:

Applicants must pass a fingerprint criminal background check, pre-employment drug screen, and registry checks including the Client Abuse/Neglect Reporting System (CANRS), Nurse Aid, Medication Aide and Employee Misconduct, List of Excluded Individuals/Entities (LEIE). Males between the ages of 18-25 must be registered with the Selective Service.

Flexibility in work hours may be required for this position. The position may be required to work overtime and/or extended hours.

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Active Duty, Military, Reservists, Guardsmen, and Veterans:

Military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position may include, but not limited to those listed in this posting. All active-duty military, reservists, guardsmen, and veterans are encouraged to apply if qualified to fill this position. For more information please see the Texas State Auditor’s Job Descriptions, Military Crosswalk and Military Crosswalk Guide at Texas State Auditor's Office - Job Descriptions.

ADA Accommodations:

In compliance with the Americans with Disabilities Act (ADA), HHSC and DSHS agencies will provide reasonable accommodation during the hiring and selection process for qualified individuals with a disability. If you need assistance completing the on-line application, contact the HHS Employee Service Center at 1-888-894-4747. If you are contacted for an interview and need accommodation to participate in the interview process, please notify the person scheduling the interview.

Pre-Employment Checks and Work Eligibility:

Depending on the program area and position requirements, applicants selected for hire may be required to pass background and other due diligence checks.

HHSC uses E-Verify. You must bring your I-9 documentation with you on your first day of work. Download the I-9 Form

Telework Disclaimer:

This position may be eligible for telework.  Please note, all HHS positions are subject to state and agency telework policies in addition to the discretion of the direct supervisor and business needs.