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