Job Description

Location: The Medical Center of Southeast Texas
Posted Date: 8/3/2020


Reporting to the Chief Medical Officer of local hospital, and working in partnership with the corporate Quality and Safety Department, will support the development and implementation of a comprehensive quality and patient safety program at a STEWARD HEALTH CARE hospital. In collaboration with system and local clinical and administrative leadership, the DQS, will support leadership, education and project management at their local hospital in accord with the quality and safety plan of the STEWARD HEALTH CARE. The goal is to improve quality, operational clinical initiatives, promote innovation and to identify/develop best practices for clinical excellence, service excellence and patient safety. The DQS will oversee hospital specific operations inclusive of hospital performance improvement, infection control, risk management, patient care assessment activity, patient safety, regulatory affairs and service excellence in partnership with other hospital leaders to promote model programs and approaches in assuring superior deliver of services. Serves as a clinical consultant for the model of local implementation for quality improvement and patient safety.

The DQS will support the implementation and monitoring of programs and activities designed to ensure that SHCS entities incorporate methods to improve the safe administration of care into all clinical processes, while developing a culture that perceives safety to be of paramount importance. Support the clinical leadership in each hospital to operationalize a common outcomes measurement and reporting system related to patient safety, and provide leadership in analyzing, prioritizing, implementing, collaborating, and communicating patient safety initiatives consistent with the STEWARD HEALTH CARE Quality and Safety Plan.


  • Facilitate formal mechanisms of communication and networking among clinical leaders at their local hospital and across SHCS including forums for information sharing, knowledge transfer, best practices, and innovative problem solving.

  • Support analytic, operational, and strategic leadership in helping to position their hospital as a quality and patient safety leader within the health care industry.

  • Provide over-site in the implementation of improved systems for tracking, evaluating, and communicating patterns in patient safety for their hospital.

  • Provide support and guidance to the clinical leadership in meeting the goals within the patient safety agenda at the local hospital. Work closely with the system’s clinical leadership, to implement alpha/pilot programs designed to eliminate the following: preventable mortality, adverse drug events, falls, pressure ulcers, surgical complications, nosocomial infections, and Joint Commission (TJC) a/or DNV-GL recommendations.

  • Provide education and coaching for front line clinical leadership in maximizing performance within the clinical decision support system.

  • Provide support in the implementation of an integrated database designed to promote more timely and accurate information related to patient safety issues and quality challenges at the local level. Develop educational programs and networking opportunities to enhance hospital’s use of failure mode and effects analysis, root cause analysis, and improvement strategies related to quality and patient safety.

  • Support the collection of patient safety data for trends and recommend changes, as appropriate, thereby improving the safety of care at the hospital.

  • Coordinate the regulatory compliance program to meet the standards identified by the TJC, DNV, DPH and CMS. Support project structure to insure all staff is involved in regulatory readiness on a daily basis. Works with administrative and clinical leadership to insure they recognize their role in preparation for regulatory readiness. Is supported by the hospital leadership in assuring this process is hospital wide.

  • Oversees the infection control program to insure practice is consistent w/regulating bodies

  • Works to support the medical peer review process in association with the hospital vice president of medical affairs and coordinates reporting to the board of registry of medicine or department of public health.

  • Recommends pi activities in collaboration with hospital leadership to insure quality and safety processes are coordinated in a multidisciplinary fashion.

  • Fosters and maintains collaborative relationships with external agencies, purchasers, and stakeholders related to quality, performance improvement and safety initiatives. Reviews and evaluates services to ensure that safety and regulatory recommendations are implemented and desired results are obtained.


  • BS or MS in health care field. 5-10 years experience in a senior clinical leader position with a strong foundation in quality and patient safety.
  • Highly motivational communication skills accompanied by the ability to analyze and present data to influence behavior, stimulate innovation, promote best practices, and drive organizational change.
  • Excellent presentation style, including the ability to present data to clinicians and staff at all levels of the organization.
  • A highly skilled change agent with demonstrable sensitivity to the interpersonal, group dynamic, organizational, political, and perceptual issues associated with change.
  • Results orientation accompanied by the skill set required to conceptualize, implement, and operationalize a user-friendly clinical excellence and patient safety program.
  • Demonstrated ability to create and sustain momentum through relationship building, and collaborative management.

The Medical Center of Southeast Texas is taking additional, necessary preparations to ensure patients can receive compassionate care in a safe, carefully managed environment – with confidence and without fear.

Our Safe and Ready program consists of a rigorous [five-point] standard ensuring patient safety, confidence and convenience:

  1. Expanded hours will allow previously cancelled procedures to be scheduled as quickly as possible.
  2. Any COVID-19 related care takes place in designated areas away from other patients and their families.
  3. Emergency Departments are reorganized to be a safe place to treat all emergency patients.
  4. A stringent cleaning policy has been implemented throughout the hospital.
  5. A strictly controlled visitor and masking policy is required for patient safety.

You can rest assured that we have made the necessary preparations to provide care in a safe, controlled and professional way.

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

Apply Online