Job Description

About us We are a community-based hospital located near the historic White Rock Lake community, that serves the Dallas, Garland, Mesquite and surrounding areas. We specialize in a wide range of services including comprehensive medical/surgical care, bariatric, cardiology, outpatient and emergency medicine. Our mission is to deliver exceptional healthcare with compassion and excellence. We are seeking compassionate, care-minded individuals to join our company and make a difference. As a member of the White Rock Medical Center team, you can advance your skills while working in a supportive and patient-focused environment. Position Summary We are seeking an experienced, forward-thinking healthcare professional to serve as the Head of Quality and Compliance , with a strong foundation in CIHQ or The Joint Commission accreditation standards. This position plays a critical role in maintaining the hospital's regulatory readiness, clinical performance, and patient safety culture. The Head of Quality and Compliance is responsible for overseeing the hospital's Quality, Performance Improvement, Patient Safety, Regulatory Compliance, and Accreditation programs. This on-site leadership role ensures compliance with all applicable federal, state, and accrediting agency requirements, including CIHQ, TJC, CMS, and Texas Health and Human Services. The role partners directly with clinical and operational leaders to support a high-reliability culture. Essential Duties and Responsibilities Leads the development, implementation, and oversight of quality and regulatory initiatives. Serves as the hospital's accreditation officer and subject matter expert for CIHQ or TJC readiness. Manages internal audits, mock surveys, and ongoing tracers to ensure continuous compliance. Facilitates performance improvement initiatives across clinical and operational departments. Oversees hospital policies and procedures related to quality, risk, infection control, and compliance. Collaborates with the CMO, CNO, and other executive leaders to drive organizational quality goals. Prepares and presents data for Quality Committee, Medical Executive Committee, and Board meetings. Monitors and reports on hospital metrics, including core measures, adverse events, and patient outcomes. Leads or supports investigations, root cause analyses (RCAs), and implementation of corrective action plans. Ensures accurate, timely submission of all required regulatory reports. Supports staff education, training, and orientation on compliance and safety standards. Knowledge, Skills, and Abilities Behavioral Standards Demonstrates professionalism, ethical leadership, and clear communication. Fosters a just culture and collaborative environment across departments. Maintains strict confidentiality and promotes data-driven decision-making. Communication/Knowledge Communicates regulatory updates, survey findings, and compliance expectations across all levels. Applies evidence-based practices and current quality improvement methodologies. Uses Lean, Six Sigma, or other frameworks to support process improvement initiatives (preferred). Collaboration/Teamwork Serves as a liaison between clinical teams, risk management, infection control, and administration. Ensures alignment between quality, safety, and operational priorities. Promotes a proactive approach to identifying risk and improving performance hospital-wide. Education & Experience Minimum of 5–7 years of experience in healthcare quality, accreditation, or compliance. Previous experience preparing for and participating in CIHQ or The Joint Commission surveys is required. Demonstrated experience in hospital performance improvement, regulatory reporting, and cross-functional leadership. Bachelor's degree in Nursing, Health Administration, Public Health, or related field required. Master's preferred. RN license (if applicable) strongly preferred. Certified Professional in Healthcare Quality (CPHQ) or equivalent preferred. CIHQ Accreditation Professional (CHAP) or Joint Commission Professional certification preferred. #J-18808-Ljbffr Vensure Employer Services

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