Manager Quality Improvement - Stroke Program

About Us Here at Baylor Scott & White Health we promote the well-being of all individuals, families, and communities. Baylor Scott and White is the largest not-for-profit healthcare system in Texas that empowers you to live well. Our Core Values are:

• We serve faithfully by doing what's right with a joyful heart.
• We never settle by constantly striving for better.
• We are in it together by supporting one another and those we serve.
• We make an impact by taking initiative and delivering exceptional experience.

Benefits Our benefits are designed to help you live well no matter where you are on your journey. For full details on coverage and eligibility, visit the Baylor Scott & White Benefits Hub to explore our offerings, which may include:

• Immediate eligibility for health and welfare benefits
• 401(k) savings plan with dollar-for-dollar match up to 5%
• Tuition Reimbursement
• PTO accrual beginning Day 1

Note: Benefits may vary based upon position type and/or level. Job Summary

• The Manager Quality Improvement for the Stroke Program provides strategic leadership and operational oversight for the comprehensive stroke program. This role is responsible for leading initiatives that drive high-quality, evidence-based stroke care, improve patient outcomes, and ensure compliance with regulatory and certification standards.

• This position manages and develops a team of stroke coordinators and leads multidisciplinary collaboration across emergency, inpatient, and procedural care settings. The manager oversees stroke program performance, including data analysis, performance improvement initiatives, and regulatory readiness (e.g., Joint Commission and state requirements).

• The role serves as a key liaison between clinical teams, leadership, and system stakeholders to standardize stroke-related processes, implement best practices, and ensure alignment with BSWH strategic priorities. The manager also leads education and training efforts to enhance stroke knowledge, competency, and adherence to clinical protocols across the organization.

• Onsite position in Temple, TX.

Essential Functions of the Role

• Plans, directs, prioritizes, communicates, and manages continuous quality improvement at local facilities and/or across BSWH.
• Ensures progress toward the BSWH goal of high reliability. Provides facilitation, mentorship, training, and materials to train and educate leadership, facility staff, and departmental staff. Helps in patient safety, quality care, and regulatory compliance.
• Develops, interprets, and reviews changes. Helps implement policies, processes, and procedures. Supports BSWH patient safety, quality priorities, and compliance with regulations.
• Ensures improvement initiatives link to the organization's strategic and tactical priorities. Emphasizes process efficiency and effectiveness. Enables breakthrough process changes and improvements.
• Monitors key processes and outcomes. Identifies performance gaps and recommends strategies for improvement. Applies data techniques and quality improvement tools to drive improvements. Tracks and examines project performance against plans to ensure return on investment.
• Serves as change agent for various stakeholders charged with clinical operations at BSWH entities.
• Works closely with facility leadership and teams. Uses audit strategies, data extraction, observation, surveys, and focus groups to improve care and service quality.
• Prepares and submits timely reports on work team progress to stakeholders. These reports include progress, potential barriers, lessons learned, and related topics for all strategic improvement priorities.
• Participates in or manages BSWH quality improvement efforts.
• Ensures successful departmental leadership by providing staffing resources and budget compliance. It also includes effective communication and team development with performance evaluation.

Key Success Factors

• Familiarity with stroke care processes
• Professional knowledge in quality performance measurement, data analysis, and project management tools and templates needed to successfully drive initiatives
• Professional knowledge of Texas, Joint Commission and CMS regulatory standards, and trends, developments and research in providing safe, high-quality care
• Excellent management, strategic thinking, investigative, facilitation, and problem-solving skills
• Excellent verbal, social, and written communication, and exceptional computer/technology skills
• Able to mentor, train and develop instructional materials to educate leadership and staff in quality, patient safety, and regulatory issues
• Able to work well with key stakeholders and teams. Identify challenges and recommend corrective actions. Prioritize tasks to achieve BSWH safety and quality goals.
• Able to manage, monitor, help, and develop direct and indirect reports to ensure personal and departmental success
• Hold or be willing to achieve SCRN, ASC-BC, CPAHA Stroke, CPHQ or other stroke-related certification within the first two years of hire.
• Licensed clinician such as nurse, physical therapist, occupational therapist, dietitian, respiratory therapist, etc. preferred.

Belonging Statement We believe that all people should feel welcomed, valued and supported. QUALIFICATIONS

• EDUCATION - Masters' or Bachelors plus 2 years of work experience above the minimum qualification
• EXPERIENCE - 5 Years of Experience

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About Baylor Scott & White Health

Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. With a commitment to and a track record of innovation, collaboration, integrity and compassion for the patient, BSWH stands to be one of the nation’s exemplary health care organizations. Our mission is to serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing. Joining our team is not just accepting a job, it’s accepting a calling!

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