
Office Hours
Monday – Friday 8AM – 5PM
Thelma R. Gaytan, MHA, MSHS, BSHA, RN, LSSGB
Associate Chief Nursing Officer (ACNO) & Director of Quality
Quality & Performance Improvement
- Responsible for compliance with all regulatory agencies – JC, CMS and Texas Health and Human Services
- Oversee Performance Improvement and Patient Safety Initiatives
- Leads and directs quality improvement activities.
- Identifies performance improvement opportunities
- Advance development and implementation of short and long-term goals
- Stratification of data to effectively analyze opportunities to reduce errors, identify problem prone processes and make decisions for improving clinical outcomes
- Implements improvement strategies utilizing evidence-based practices
- Educates members of the healthcare team on performance improvement methodologies
- Assists with strategic planning and resource utilization
- Establishes and promotes collaborate and effective relationships with physicians, and interdisciplinary team members
- Assists the Chief Nursing Officer in daily operations
- Active member with National Association for Healthcare Quality (NAHQ)
- Certified as Lean Six Sigma Greenbelt