Quality And Safety Consultant

UT Health East Texas Tyler , TX 75701

Posted 7 months ago



The position of Quality and Patient Safety Director at UTHET is accountable for assisting the organization to improve quality, safety, and reduce operational risk exposure through performance improvement processes and meeting regulatory and accreditation requirements. They will assist in the implementation of UTHET's Quality/Clinical effectiveness function. This position supports a culture of high reliability and the measurement of care quality identifying opportunities and executing on strategies for performance improvement in the following areas of the organization:

  • Outcomes - highly reliable processes, delivering exceptional outcomes and/or optimal health

  • Safety Deliver the safest care to patients driven through leadership and a culture of high reliability

  • Accreditation-Ensures all regulatory requirements are managed and highly functional

  • Experience of Care - relationship-centered care grounded in empathy, dignity, respect and collaboration

This position is a resource to the Specialty and Rehab hospitals and drives organizational performance that is built on relationships, a shared vision of excellence, and an environment of achievement and local accountability.


This is a Specialty and Rehab based role with key organizational relationships across UTHET with a specific focus on the delivery of the Safety and Accreditation. This position reports to the Director of Safety and Accreditation. The position will participate in key committees across the system to drive culture and results.


  • Support a proactive, comprehensive strategic Quality agenda that inspires caregiver engagement, inter-professional collaboration, the identification and use of evidence-based practice and management among all entities in the system while differentiating UTHET as a high reliability organization nationally.

  • Provides accurate and meaningful data to teams, committees and physician groups by understanding data dictionaries and using appropriately, using self-coded data sheets, assisting in determining appropriate data to collect by asking right questions and identifying correct populations, and using working knowledge of existing databases to obtain data already being collected.

  • Appropriate knowledge and application of basic statistical tools, such as, standard deviation, frequency distributions, histograms, and pareato charts.

  • Applies quality improvement methodologies as a quality representative/facilitator for PI Teams and as a consultant to provide basic CQI or statistical tools.

  • Evaluates and makes recommendations for system improvements using quality data, event and regulatory compliance reports.

  • Provides project management to assigned teams by providing leadership to focus areas and by utilizing facilitation and assessment skills to develop evidence-based initiatives.


  • Drives all regulatory functions on the local level.

  • Applies a current working knowledge of regulatory compliance standards as appropriate to assignment or specialty.

  • Provides advanced consultation and support by collaborating with peers throughout the corporation to develop methods and plans to meet standards, participating in the writing or development of new policies, procedures and guidelines, researching literature and outside sources to identify new methods, technologies, or approaches for compliance, ensuring compliance to regulatory support and assessing compliance to standards to ensure a safe and consistent care environment to multiple areas and settings.


  • Leads Mission Zero: Our Culture of Safety on the local level.

  • Leads and/or functions as the Risk Manager.

  • Applies a current working knowledge of national, local, and system patient safety standards and trends as appropriate to assignment or specialty.

  • Provides collaboration and consultative support to Risk Management, Compliance, Medical Staff, Nursing, and others by compiling reports with recommendations from appropriate sources, participating in maintenance of applicable Safety Plans, networking across departments and facilities to achieve objectives and goals, participate or facilitate patient safety improvement teams, and engages and interacts with staff at all levels to encourage ownership of initiatives.


  • Advocate and support standardization by educating focus areas to centrally developed policies, procedures, processes, and forms and assisting/participating in corporate teams with the development of policies, procedures, processes, and forms.

  • Participate in development, implementation, revision, and review of policy, procedures, protocol, guidelines, and forms, when appropriate for focus areas.


  • Provides education to focus areas regarding Quality Monitoring and Improvement, Regulatory Compliance, Patient Safety, Risk Management, Medical Staff Services and Practice Standardization and Policies.


  • Support quality measurements for internal use.

  • Support the deployment and optimization of the electronic health record to maximize safety, quality outcomes, clinical effectiveness and efficiency.

  • Advance, with others, the use of predictive analytics and deep learning computing to improve the health, experience and quality of care of those we serve.

Job Requirements


Minimum Requirements:

  • Bachelor's degree in Business, Healthcare Administration, Public Health or other business related field. Education must be obtained through an accredited institution and will be verified.

  • Experience leading successful Quality Improvement projects.

  • Experience with change management with the ability to provide leadership in the adaptation and implementation of new processes and /or technology that enhance Quality.

  • Effective verbal, written and interpersonal communication skills.

  • Experience overseeing patient safety programs.

  • Experience leading teams.

Physical Requirements:

  • Interact with others requiring employee to verbally communicate as well as hear and understand spoken information.

  • Operate computers, telephones, office equipment, and manipulate paper requiring the ability to move fingers and hands.

  • See and read computer monitors and documents.

Preferred Qualifications:

  • Experience with external entities that drive and support Quality approaches and standards, including government agencies, academic institutions, universities and related organizations of higher education, and other public institutions is preferred

  • Trained in improvement science (i.e., Six Sigma, Lean, UT System CSE or DMAIC)

  • Experience working in a complex health system (hospitals, ambulatory clinics, post-acute care, etc.)

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Quality And Safety Consultant

UT Health East Texas