Director of Quality Services

Nexus Children's Hospital

About Nexus Children’s Hospital – Shenandoah

Nexus Children’s Hospital – Shenandoah provides specialized pediatric healthcare services in a compassionate, patient-centered environment focused on delivering exceptional clinical outcomes. Our team is committed to bridging medical care, rehabilitation, and behavioral health services while maintaining the highest standards of safety, compliance, and quality for every child and family we serve.

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Position Summary

Under the general supervision of the CEO, the Director of Quality Services is responsible for overseeing hospital-wide quality, performance improvement, compliance, accreditation, and patient safety initiatives. This leadership role serves as the facility’s Compliance and Privacy Liaison and collaborates closely with all department leaders to ensure organization-wide compliance with regulatory, accreditation, and operational standards.

The Director of Quality Services plays a vital role in driving continuous improvement initiatives, promoting a culture of safety, and ensuring compliance with DNV standards, Medicare/Medicaid regulations, HIPAA requirements, and hospital policies and procedures.

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Job Responsibilities

Performance Improvement & Quality Oversight

• Direct hospital-wide Performance Improvement (PI) activities and initiatives.
• Monitor, aggregate, and evaluate quality and compliance data.
• Educate staff and physicians regarding PI programs, processes, findings, and outcomes.
• Facilitate PI teams to improve hospital processes, patient outcomes, and patient safety.
• Develop and present quality reports, action plans, and recommendations to leadership teams, committees, and governing bodies.
• Assist department leaders with indicator tracking and compliance activities.
• Audit medical records to ensure compliance with designated standards and criteria.
• Coordinate continual hospital-wide compliance with DNV accreditation standards.
• Ensure ongoing review of hospital practices to maintain licensure and accreditation compliance.

Compliance & Risk Management

• Serve as the hospital Compliance Liaison and Privacy Liaison.
• Ensure compliance with all regulatory agencies governing healthcare delivery and accrediting body standards.
• Investigate incidents, occurrences, near misses, and sentinel events with appropriate follow-up and corrective action plans.
• Review incident reports and monitor trends for potential risks or concerns.
• Conduct internal compliance investigations as needed.
• Provide incident and statistical analysis reports to Executive Leadership and the Governing Board.
• Work collaboratively with the Safety Officer to implement and maintain patient and employee safety programs.

Operational Leadership

• Develop new avenues for facility growth and operational improvement.
• Maintain positive and collaborative relationships with physicians and community partners.
• Participate in professional and community organizations as a hospital representative.
• Assist with development and implementation of emergency preparedness and safety plans including:
  • Fire safety
  • Hazardous materials
  • Disaster preparedness
  • Utilities management
  • Security
  • Medical equipment safety
  • Evacuation procedures
• Review and respond to recommendations from regulatory and inspection agencies.
• Collaborate with department leaders on organization-wide policies and procedures.
• Communicate operational concerns and needs to executive leadership as appropriate.
• Perform additional duties as assigned.

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Position Qualifications

Education

• Bachelor of Science in Nursing (BSN) or equivalent clinical background preferred.
• Continuing education in nursing practice, patient safety, and quality improvement preferred.
• Extensive knowledge of DNV standards and Medicare/Medicaid regulations required.

Experience

• Experience in:
  • Performance Improvement
  • HIPAA Compliance
  • DNV Accreditation
  • Risk Management
• Previous leadership or management experience preferred.
• Extensive experience conducting internal investigations and compliance reviews.
• Healthcare industry experience required.

Licensure/Certification

• Current Registered Nurse (RN) licensure in the State of Texas preferred.
• Current AHA/BLS certification required.

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Why Join Nexus Children’s Hospital – Shenandoah?

• Opportunity to lead hospital-wide quality and compliance initiatives
• Collaborative and mission-driven leadership environment
• Meaningful impact on pediatric patient safety and outcomes
• Growth-oriented healthcare organization committed to excellence
• Competitive compensation and benefits package