• Director, Quality, Infection Control, Employee Health

    Posted Date 1 week ago(10/10/2018 3:26 PM)
    Job ID
  • Overview

    AccessHealth is a private, not-for-profit community health center established in the community in 1975. We provide quality health care services for the entire family as a Federally Qualified Health Care Center with membership in the Texas Association of Community Health Centers.

    We are always looking for dedicated, talented professionals willing to share their hearts with those we serve. Being part of our team means performing to a higher standard. AccessHealth's providers, employees, volunteers and board members will collaborate with patients, their families and other community organizations to enable patients to achieve a personal state of wellness. We address our patient's physical, social, and psychological needs through the offering of high quality services with compassion, competence and integrity.


    Identifies, implements and directs process improvement activities that provide more efficient, streamlined workflow in the healthcare clinic environment. Responsible for ensuring the coordination, completion and communication of performance improvement activities as assigned and as necessary to maintain compliance with Federal, State and funding organizations requirements. Works closely with all levels of staff and Providers to ensure identification, education, implementation and monitoring of quality, risk management and performance improvement measures and programs.


    Directs the employee health program, ensuring organization compliance with all OSHA requirements and meeting the standards necessary for a Federally Qualified Health Center.



    1. Develops and spearheads the quality, risk management, performance improvement, education and safety initiatives in accordance with AccessHealth policies and procedures. Responsible for active leadership in assessing, implementing, ongoing evaluations and revisions of those programs.
    2. Works closely with COO and Compliance officer to ensure AccessHealth policies and procedures are in compliance and maintain the quality standards required/recommended by Federal, State, Local grantors and regulatory agencies.
    3. Serves as a role model to communicate initiatives and instill a culture of safety for patients and staff. 
    4. Implement programs and tools to monitor outcomes and metrics to report results of process improvement activities.  Evaluate and facilitate mechanisms to increase the use of 5 whys, incident reports, patient and staff complaints, near misses, etc. as tools to improve systemic processes and not merely a punitive mechanism.
    5. Direct root cause analysis process, clinician peer review, etc. to support clinician competency, effective processes and quality care.
    6. Recommend and coordinate the implementation of policies and procedures to improve patient care and utilization of clinic resources as directed by analysis of quality measures and based on the needs of the involved governmental agencies and community served.
    7. Maintain positive relationships with staff, and patients, agency wide, to understand issues, mitigate risk and resolve problems.
    8. Work with clinical operations & support leaders to establish a comprehensive plan/process for patient satisfaction and complaints. Facilitates ongoing reviews of patient satisfaction
    9. Organizes the collection of data to process reporting requirements.
    10. Responsible for completion of appropriate reports.  Submits statistical information as required.
    11. Works with Director of Clinical Operations and site supervisors to maintain ongoing readiness for local, state, grantor, insurance requests for surveys/ audits.  Develops and maintains a database with appropriate regulatory audit results and communicates to leadership and staff as appropriate.
    12. Keep abreast of changes in healthcare quality, best practices, regulatory &, grantor requirements.  Ensure communication with leadership and staff about changes.
    13. Attend workshops, conferences and seminars necessary for professional growth and to keep AccessHealth at the forefront of issues and trends.
    14. Represent AccessHealth at community activities, meetings, conferences as required.
    15. Performs all other duties as assigned by management.





    1. Current and valid Texas RN license or clinical experience working directly in a clinical setting.
    2. Current and valid Texas driver’s license.
    3. Baccalaureate Degree or Associate Degree with 2 years of experience with quality and PI.


    1. BSN and Master’s Degree
    2. Professional certification in Certified Professional in Healthcare Quality (CPHQ) or Certified Professional in Healthcare Risk Management (CPHRM)


    1. Experience with process/performance improvement, risk management, clinical quality, and patient satisfaction. LEAN/Six Sigma, OSHA, HIPAA and or The Joint Commission experience.
    2. Experience leading teams formally and informally, supervisory experience, demonstrated ability to interact with patients and all levels of staff in the organization.
    3. Thorough working knowledge of medical clinic operations, scope of practice and quality/ regulatory requirements applicable to federal, state and private funders, insurance and clinical standards of care applicable to RNs, LVNs and health aides.
    4. Experience evaluating, communicating and implementing best practices and evidence based practice.
    5. Experience with data management- establishing, evaluating, reporting, & monitoring metrics.
    6. Proficient in computers including knowledge and use of Microsoft office applications, electronic medical records
    7. Excellent decision-making, problem solving and assessment skills.
    8. Ability to handle multiple projects, well organized and self-directed
    9. Ability to think critically, evaluate situations and champion effective change.
    10. High ethical standards, positive, can-do attitude
    11. Proficient interpersonal relations and communicative skills
    12. Excellent verbal and written communications skills.
    13. Flexible and able to handle multiple projects simultaneously.
    14. Consumer advocate for quality health care and services.

    EEO Statement

    AccessHealth is an Equal Opportunity Employer and Prohibits Discrimination and Harassment of Any Kind: AccessHealth is committed to the principle of equal employment opportunity for all employees and to providing employees with a work environment free of discrimination and harassment. All employment decisions at AccessHealth are based on business needs, job requirements and individual qualifications, without regard to race, color, religion or belief, national, social or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV Status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate. AccessHealth will not tolerate discrimination or harassment based on any of these characteristics. AccessHealth encourages applicants of all ages.


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