Job Description

Extended Job Title
Assistant Director - Quality Improvement

Org Level 1
Texas Tech Unv Hlth Sci Ctr El Paso

Position Description
Performs varied and complex administrative duties in the management and coordination of a large specialized project and/or program. Requires independent judgment and application of established policies and procedures. Works under general supervision with evaluation based on overall results obtained

Requisition ID

Travel Required
Up to 25%

Major/Essential Functions
  • Conducts comprehensive reviews of regulatory agency websites, literature, policies and procedures, and requirements (CDC, CMS, ISMP, OSHA, FDA, DSHS) for updates, changes, alerts that are vital to the organization and takes appropriate action when needed
  • Conducts comprehensive reviews of Joint Commission literature, standards, and websites for updates, changes, or alerts and communicates them to leadership as appropriate
  • Verifies information, answers inquiries, address issues, and resolve problems regarding Joint Commission standards or regulatory compliance
  • Initiates the collection, organization, and analysis of data from all clinical departments and develops reports to track quality indicators
  • Serves as a liaison to staff, faculty, and residents to explain, conduct trainings, and provide technical assistance on Joint Commission and regulatory requirements
  • Utilizes Procurement Card to obtain necessary supplies, subscriptions, memberships, and registration fees as applicable. Maintains appropriate documentation as necessary for compliance with PCard guidelines
  • Coordinates and schedules BLS classes for organization staff, faculty, residents, and students
  • Serves as Unit Safety Officer (USO) ensuring all staff in the unit are informed of emergency and evacuation procedures, location of safety materials, and appropriate procedures in the event of an incident involving unit staff

Grant Funded?

Minimum Hire Rate

Pay Basis

Work Location
El Paso

Preferred Qualifications
  • Working knowledge of Joint Commission Ambulatory standards
  • Proficient in the use of Microsoft Office suite and GE Centricity EMR

HSC - El Paso

Quality Improvement Elp

Job Type
Full Time

Pay Statement
Compensation is commensurate upon the qualifications of the individual selected and budgetary guidelines of the hiring department, as well as, the institutional pay plan. For additional information, please reference the institutional pay plan on the Human Resources webpage.

Job Group
Business Professionals

Occasional Duties
  • Conducts regular environmental surveys at all clinical locations to determine compliance with Joint Commission requirements, institutional policies, national and state regulations, laws, and requirements
  • Coordinates Nurse Manager Committee meetings
  • Coordinate all aspects of Clinical Operations Committee Meeting
  • Coordinates Joint Commission Readiness trainings
  • Provides support and collaborates in the planning, development, implementation, and analysis of clinical policies
  • Orders and maintains inventory of consumable office and medical supplies as used by the Offices of Quality Improvement and Occupational Health
  • Develops trainings for staff identified by clinical departments in the areas of Joint Commission/regulatory standards and quality improvement projects
  • Develop, modify, maintain, and distribute trainings using the ACME system
  • Initiate implementation of the Employee Safety Survey, receive data from the survey, develop reports and presentations on the results of the survey
  • Conduct regular medical record reviews for compliance with policy and charting requirements by staff and faculty
  • Maintain property inventory for controlled and capitalized assets for the Offices of Quality Improvement and Occupational Health
  • Organize and participate in Joint Commission mock surveys to ensure institutional compliance in Joint Commission standards
  • Assist with the development and maintaining of the operational budget for the Office of Quality Improvement and Office of Occupational Health
  • Create and distribute designation hang tags for all clinical staff, faculty, residents, and students
  • Collaborates in the planning of leadership rounds.  Maintains notes and generates follow up reports and action items based on leadership round results
  • Provides non-clinical supervision to Quality Improvement and Occupational Health staff in the absence of the Senior Director


EEO Statement
As an EEO/AA employer, the Texas Tech University System and its components will not discriminate in our employment practices based on an applicant’s race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, genetic information or status as a protected veteran.


Required Qualifications
  • Bachelor's degree in the area of specialization or closely related field
  • Three years of related administrative and technical experience
  • Additional job related education may be substituted for the required experience on a year-for-year basis

Does this position work in a research laboratory?

Jeanne Clery Act
The Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act is a federal statute requiring colleges and universities participating in federal financial aid programs to maintain and disclose campus crime statistics and security information. By October 1 of each year, institutions must publish and distribute their Annual Campus Security Policy & Crime Statistics Report (ASR) to current and prospective students and employees. You can locate this report through our website at:

Application Instructions

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