Quality Assurance Director-Manager III

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.

Brief Job Description:

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.

The Quality Assurance Director (QAD) performs complex supervisory and consultative work requiring specialized knowledge in the planning, development, implementation, and monitoring of quality assurance systems. Ensures the facility conforms to the conditions of participation for the facility as a Centers for Medicaid and Medicare Services (CMS) provider serving persons with mental health diagnoses, the Joint Commission (TJC) standards, and all other relevant state and federal laws, rules, and regulations.  Interprets regulations/standards, develops, and disseminates policy, performs advanced consultative services to program staff, and coordinates a comprehensive system of implementing and reporting on quality enhancement efforts. Ensures a system is maintained to effectively assess service delivery and compliance with HHSC policies and procedures and CMS conditions of participation, including analyzing and evaluating program operations, procedures, and systems and recommending modifications for improvement. Develops and ensures provision of in-service/training modules to address issues as needed. Analyzes data from multiple sources for trends, systemic issues, and areas for improvement, including verifying accuracy of data.  Proactively identifies issues and provides solutions.  Implements directives. Responds to crisis/emergency situations and takes immediate action to resolve the issue(s).  Develops, schedules, and prioritizes processes for achieving established goals.  Oversees development and implementation of plans of correction and other plans of correction.  Develop reports as directed.  Hires, develops, plans, assigns, and supervises the work of others. Oversees the Quality Assurance/Quality Management team and serves on and/or chairs other committees and work groups.  Acts as the liaison between HHSC Regulatory, CMS, TJC and the facility. Works collaboratively with the Superintendent and all other department leads. Performs related work as assigned.  Serves in the on-call rotation to respond to facility issues after hours and on weekends. Works under the general supervision of the SH Superintendent, with moderate latitude for the use of initiative and independent judgment.

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.

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.

Attends work on a regular basis and may be required 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.   Serves in the capacity of the Executive or Administrator on Duty in rotation and is on-call as needed.  

Provides leadership and plans, assigns, and supervises the daily activities of quality assurance department and client records department staff.  Directly supervises program auditor(s), data analysts, records coordinators, Clinical Safety Coordinator and/or Nurse Auditor(s) and administrative/clerical staff.  Supervises other types of staff as needed depending upon SH structure.  Hires, trains, and promotes personal and professional growth of the employees within the department so that a competent workforce is maintained. Ensures that all departmental staff are compliant in training per agency and facility standards. Conducts performance evaluations of assigned staff to give employees timely feedback on their performance and oversees staff development plans and activities.  Takes action to improve employee retention and reduce turnover. 

Directs and oversees the functions of the quality assurance department including providing support to departments in data collection, monitoring, analysis, and reporting. Ensures the collection of information in a timely and efficient manner and ensures the use of that information to identify performance issues and make decisions. Proactively identifies potential problems. Reports potential and actual problems to the appropriate supervisor/manager for corrective action.  Provides feedback to discipline coordinators/department leads for process improvement. 

Oversees the Quality Improvement Council (QIC) process by reviewing the agenda and schedule of presentations, advising on presentation content, reviewing all reports, and, if requested by the Superintendent, facilitating the meeting.   Attends the daily Morning Report meeting to ensure that injuries and incidents are addressed appropriately.   Functions as a member of the Executive Team, the QIC, and the Medical Executive Committee (MEC).  Interfaces with the state office leadership via regular conference calls and face to face meetings.  Participates on other work groups as needed to promote collaboration and operational effectiveness.

Acts as the liaison between HHSC-Regulatory, CMS, TJC and the facility before, during and after monitoring visits. During visits from HHSC-Regulatory, CMS and TJC meets with surveyors at the entrance and exit meetings. Ensures surveyors receive all documentation requested, providing contact information for staff, patients and families as needed.  Answers surveyor questions regarding policies/procedures.  Notifies all required parties of the entrance of HHSC-Regulatory, CMS and TJC at the SH in accordance with established protocols. Responds to Regulatory, CMS and TJC concerns and takes immediate action to resolve the issue(s).

Oversees the work of staff auditors to ensure statistical analysis of data and database design is conducted, to maintain a center-wide list of all data collected by department, to maintain the databases that the QA and discipline departments use to enter results from monitoring tools. Ensures that data is collected via a facility-wide monitoring system that can be trended by required parameters. Collaborates with, and oversees data analyst collaboration with, the state office data analysts to validate and correct datasets in the electronic records system (such as CWS) and improve data integrity.

Oversees the development and submission of a plan of correction (POC) for all deficiencies cited by HHSC-Regulatory, CMS or TJC.  Ensures POCs include measurable outcomes and appropriately address the identified issue(s), that the outcomes are monitored.  Ensures that all due dates noted in the POC are met, and that evidence supporting the plan is collected and organized in accordance with the SH protocol.  Presents the evidence to the surveyors upon their return visit.

Conducts face-to-face meetings with each department lead as necessary.  Ensures samples are pulled and shared with the appropriate areas for internal monitoring.  Makes monitoring assignments to QA staff.  Maintains a system to accurately reflect all monitoring to be reviewed by the QIC.  Works with the SH Superintendent to ensure all necessary data is reviewed by the QIC on a recurring schedule.

Oversees the analysis, implementation, and documentation of HHSC and SH policies, and monitors compliance with policies and procedures as directed. Provides technical guidance for staff within the department or facilitates getting that guidance from other subject matter experts when needed.  Develops localized policies and procedures to implement state policy and ensures those documents are posted on the required site and are updated as needed. Develops in-service/training modules as needed to address issues.  Ensures all staff are trained on policy changes as required.  Ensures in-services/trainings on policies and procedures are conducted in conjunction with POCs and documentation is accurately maintained. Prepares any required reports. 

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.

Knowledge, Skills and Abilities (KSAs):

Knowledge of CMS conditions of participation, The Joint Commission standards, interpretive guidelines, and survey process. 

Knowledge of Texas Administrative Code, HHSC policies and procedures related to State Hospitals.

Knowledge of and experience in ensuring the provision of quality services, treatment, training and supports for patients with a mental health diagnosis.

Skills in defining problems, collecting data, establishing facts, conducting root cause analysis.

Skill in using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems.

Skills in using computers and agency/facility software including, but not limited to, Microsoft Word, Excel, PowerPoint, Access, Outlook, and SharePoint.

Skill in motivating all levels of staff.

Skill in facilitating change.

Skill in writing quality improvement plans.

Ability to develop written policies/guidelines to ensure facility compliance with applicable standards. 

Ability to manage business functions and activities of the assigned department.

Ability to gather, assemble, and correlate data for trend analysis.

Ability to effectively facilitate work groups and meetings.

Ability to organize and present information effectively, both in spoken and written word, to a wide variety of audiences.

Ability to analyze and solve complex problems and to make effective decisions affecting the overall operation of the facility.

Ability to plan, assign, and supervise work of others.

Ability to manage time with latitude for independent judgement, 

Ability to maintain flexibility in work hours, which may require overtime or extended hours.

Registrations, Licensure Requirements or Certifications:

None

Initial Screening Criteria:

Bachelor’s degree from an accredited college or university; and three (3) years of work experience in service delivery systems for persons with mental health diagnoses and/or in quality assurance.

        Or

Seven (7) years of work experience in service delivery systems for persons with mental health diagnoses, including at least two (2) years in a role with duties relating to quality assurance.

AND

Experience with the standards, applicable rules, and laws related to CMS conditions of participation, The Joint Commission standards or other acute or hospital settings.

Experience with ensuring quality services for persons with mental health diagnoses is preferred.

Experience leading and/or supervising employees is preferred.

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.

All applicants must be at least 18 years of age to be considered for employment at a state-operated facility. Waco Center for Youth applicants must be 21 years of age.

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

Compliance with HHSC immunization policy and state hospital operating procedures related to immunizations is required. According to the Centers for Disease Control and Prevention, healthcare workers are at significant risk for acquiring or transmitting hepatitis B, measles, mumps, rubella, varicella (chicken pox), tetanus, diphtheria, pertussis (whooping cough), and influenza. All these diseases are vaccine preventable. Vaccines may be provided. As a result, state hospital policy requires employees be vaccinated according to their level of contact with individuals. In the event you choose to not be immunized for the influenza virus, you may be required to wear a mask and take other protective measures.

Review our Tips for Success when applying for jobs at DFPS, DSHS and HHSC.

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