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Sr Director of Quality - TX Northeast


System Locations:

CHI St. Joseph Health Bellville Hospital

44 North Cummings Road
Bellville, TX 77418

CHI St. Joseph Health Burleson Hospital

1101 Woodson Drive
Caldwell, TX 77836

CHI St. Joseph Health Grimes Hospital

210 Judson Street
Navasota, TX 77868

CHI St. Joseph Health Regional Hospital

2801 Franciscan Drive
Bryan, TX 77802

Seton Medical Center Harker Heights

850 W Central Texas Expy
Harker Heights, TX 76548


The Senior Director of Quality functions as the liaison between the National Quality, Risk & Safety Directors and Committees and the QRSDs and Medical Directors at the individual sites.  The SDQs report to the National Director of Quality (NDQ).  The SDQs receive direct reports from the QRSDs or Medical Directors or Assistant Medical Directors (if there is no QRSD at that site). The primary responsibility of the SDQ is to ensure optimal quality performance in the Region/Division.

Job Responsibilities

National Level

  • Maintain a monthly meeting [by phone] schedule with the NDQ to discuss issues, priorities, etc.
  • Report quality metric performance regularly to the NDQ for respective Region/Division.
  • Participate in the monthly National Peer Review Meetings and, the Quarterly National Peer Review Quarterly Operations Meetings. For the NPR Monthly Meeting this includes preparation of a PP presentation covering cases, trends and priorities.
  • Participate in Quarterly Quality Presentations with Regional Presidents/VPs with NDQ and other SDQs.

Regional Divisional Level

  • Responsible for quality metric performance in respective Region/Division as established by the NDQ.
  • Develop and implement solutions to improve quality metric performance in respective Region/Division and share best practices with NDQ and other SDQs.
  • Work with Health Care System’s Senior Leadership in your Region/Division to improve and develop quality programs.
  • Ensure distribution, familiarity and use of educational tools developed at USACS throughout Region/Division

Individual Site Level

  • Disseminate national, quality, risk and safety priorities to the site leadership to include:
    • Regular meetings [at least quarterly] via WebEx with the QRSDs assigned to you
    • Distribution of the Monthly Quality Update to the QRSD
  • Support your Site QRSDs by:
    • Receiving and reviewing quality, risk & safety data from the site QRSD and synthesizing learning points for transmission to the NDQ
    • Support QRSD’s obligations to the hospital and support their efforts to develop resolutions for hospital concerns and requests
  • Monitor Incident Reporting at your sites, including frequency
    • Review of incidents reported for your sites to include scoring and comments
    • Monitor follow-up with site leadership and/or provider if required
    • Insert Level 3/4 Peer Review cases on IRP
  • Ensure that the following audit/review functions are being performed at each of your sites:
    • Peer Review Meetings where quality/safety cases are discussed
    • New provider audits
    • 72-Hour returns who are admitted
    • Focused reviews requested by hospital site administration
    • Company-wide reviews
  • Review risk management policy compliance/implementation at your sites
  • Review FailSafe compliance and review of fallouts at your sites
  • Monitor and review CEDR Metrics that are selected to measure quality, utilization or stewardship of sources. 


CHI St. Joseph Health Regional Hospital is the anchor facility for CHI St. Joseph Health System. The newly designed Emergency and Trauma Center, which opened in 2016, offers the community's only Level II Trauma Center for a nine-county area, along with an extensive inpatient and outpatient surgery program, and is known throughout the region for its cardiac, cancer and rehabilitation programs. Most of the St. Joseph ED staff have clinical faculty appointments available through the Texas A&M Health Science Center, allowing physicians the opportunity to teach students and residents. The hospital was named Designated Trauma Facility of the Year for 2016 by the Texas Department of State Health Services, the Office of Emergency Management Services and Trauma Systems Coordination.

Emergency Department

  • ED Volume: 51,000
  • ED Beds: 26, plus 4 vertical fast track rooms and 3 locked-down psychiatric beds
  • Patients/Hour: 2.3
  • Admission Rate: 25%
  • Trauma Designation: Level II
  • Certified Chest Pain Center and Primary Stroke Center
  • Coverage: 8- and 9-hour shifts with 41 hours of physician coverage and 36 hours of APP coverage per day
  • Scribe program
  • Qualifications: BC/BP in Emergency Medicine
  • Documentation: Picis CPOE EMR


From the historical sites and hand-crafted Texas wines to Broadway productions and world premier ballet, there is something for everyone in Bryan and College Station. The energetic and progressive area boasts 924 acres of parks and statewide reputation for quality athletic events. It has grown up alongside Texas A&M University, a major educational and research institution with about 50,000 students.
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