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Director of Clinical Quality and Operational Effectiveness

We Are Hiring

Director of Clinical Quality and Operational Effectiveness  - Total Quality Management 004 - Full-Time, Day - Seton Medical Center Hays - Kyle, TX

South Market

Why Join Ascension?

Ascension Seton, based in Austin, Texas, is a faith-based non-profit healthcare system founded in 1902 by the Daughters of Charity. Called to be a sign of God’s unconditional love for all, Ascension Seton strives to expand access to high-quality, low-cost, person-centered care and services. Ascension Seton operates more than 100 clinical locations, including four teaching hospitals which serve as training sites for Dell Medical School at The University of Texas.

Ascension is a faith-based healthcare organization dedicated to transformation through innovation across the continuum of care. As one of the leading non-profit and Catholic health systems in the U.S., Ascension is committed to delivering compassionate, personalized care to all, especially to those most in need. In FY2018, Ascension provided nearly $2 billion in care of persons living in poverty and other community benefit programs.


What You Will Do

As a Director of Clinical Quality and Operational Effectiveness  with Ascension Seton, you will have the opportunity to direct quality and patient safety activities and resources. We will be looking for leaders in these roles with solid people management experience and the demonstrated ability to wear many hats in managing multiple priorities under tight timelines.  Ideally, we’d like folks with clinical backgrounds and quality, patient safety, accreditation, and performance improvement skills and experience.  These directors will work collaboratively with site leadership for their respective sites, as well as with our other site quality directors and the network leaders in Care and Performance Excellence (CAPE); e.g., Performance Improvement, Analytics, Network Quality. 


  • Oversees and advises Site Triad regarding local Quality, Safety, Risk, Experience, Performance Improvement activities
  • Organizes Site Patient Safety Committee, Site Accreditation Readiness Team, Experience/Family Engagement Teams as applicable
  • In matrixed partnership with Network leaders, directs local team, to include Local Quality Coordinators, Infection  Preventionist(s), Site Safety/EOC Officer, Patient Representative
  • Monitors and ensures compliance with all accreditation requirements and safety and experience performance expectations
  • Organizes representation to network improvement teams and leads implementation of applicable network  and local PI activities
  • Organizes local “SWAT” event analysis review process and assists network resources in root cause analyses as appropriate
  • Manages Daily Brief / Huddle process, including associated follow-up action items


  • Experience and knowledge of total quality management principles, performance improvement techniques and principles of improvement science, patient and associate safety methodologies, clinical data analysis and regulatory requirements is required. 
  • Computer knowledge in Microsoft products, the computerized medical record, clinical care protocol development process, and use of clinical databases is required 
  • Excellent verbal and written communication skills as well as presentation skills, excellent leadership, organizational, analytical, management and project management skills; and facilitation experience with medical teams, including physician participants, are required
  • Strong working knowledge of ongoing monitoring techniques (including criteria development) is strongly preferred

What You Will Need


  • Diploma 
    • High school diploma/GED with 2 years of experience, or Associate's degree, or Bachelor's degree required.
    • Master's degree preferred.

Work Experience:

  • 5 years of experience required.
  • 10 years of experience preferred.
  • 2 years of leadership or management experience required.
  • 5 years of leadership or management experience preferred.

Preferred experience and education:

  • Bachelor’s degree in management or a healthcare related field from an accredited four year university is required
  • Master’s degree in Nursing, Business Administration, Healthcare Administration or related Healthcare field is preferred
  • Six (6) years of experience in performance improvement and healthcare related leadership experience is required. Three (3) years of clinical training and practice is strongly preferred. Preferred Master’s degree can substitute for two (2) of the required years of experience
  • Certified Professional in Healthcare Quality (CPHQ), other certification in healthcare quality or process improvement is preferred
  • Six Sigma or similar quality improvement training, project management training is preferred
  • Experience with healthcare regulation and accreditation including TJC accreditation and magnet designation is preferred
  • Training and experience in clinical data analysis and statistics, evidence based practice, and/or research is preferred

Equal Employment Opportunity

Seton Healthcare Family is an equal employment opportunity / Affirmative Action employer and complies with all applicable federal, state and local equal employment regulations and laws. It is the policy of the Seton Healthcare Family to afford equal employment opportunities to all employees and prospective employees without regard to their race, color, ancestry, religion, sex, sexual orientation, national origin, age, physical or mental disability, citizenship status, veteran status, gender identity or expression, or any other characteristic or status that is protected by federal, state, or local laws. This policy applies to all personnel actions, such as hiring, promotion, transfer, demotion, termination, layoff and all other conditions and privileges of employment in accordance with applicable federal, state, and local laws.

Affirmative Action goes beyond the concept of equal employment opportunity. Affirmative Action policies and programs are required to overcome the present effects of past discrimination and to achieve equal employment opportunity for members of groups that are or have been formerly under-represented. Affirmative Action policies and programs are tools whereby additional efforts are made to recruit, employ and promote qualified members of formerly excluded groups, even if that exclusion cannot be traced to particular discriminatory actions. Through specific and result-oriented activities, Seton Healthcare Family’s goals are to ensure that every person is given full consideration through equal employment opportunity policies and practices and to achieve a representative workforce through its affirmative action efforts.
It is further the policy of the Seton Healthcare Family to encourage vendors, contractors, affiliate institutions and others doing business with the Seton Healthcare Family to observe the principles of Equal Employment Opportunity and Affirmative Action.

Seton Healthcare Family is an EEO/AA employer: M/F/Disabled/Vet.

For further information regarding your EEO rights, click on the following link to the “EEO is the Law” poster:

EEO is the Law Poster Supplement

Please note that Ascension will make an offer of employment only to individuals who have applied for a position using our official application. Be on alert for possible fraudulent offers of employment. Ascension will not solicit money or banking information from applicants.

Job ID: 347680
Category: Qlty Risk Mgt and Compliance
Facility: TXAUS Network Services
Ministry: Ascension Seton, TX
Location: Kyle, TX

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