Manager, Hospital Quality, Enterprise Quality and Patient Safety

Memorial Hermann Health System

About The Position

The Hospital Quality Manager manages the hospital quality and patient safety program and supervises clinical robust process improvement activities that support evidence-based practices and reduce medical and health care errors and other causes of unintended adverse outcomes. The manager oversees improvement projects using high-reliability methods, monitors quality measures, and supports ongoing regulatory compliance and readiness. The role educates leaders, physicians, and staff on high-reliability methodologies, including system-based causes of medical error, and works closely with hospital leadership to advance strategic goals and objectives. The manager supervises the collection, analysis, and reporting of hospital quality and patient safety data related to cost containment, performance improvement, and outcomes. The role coordinates reporting of improvement activities through forums including Monthly Operating Reviews and Quality Committees, promotes interdisciplinary collaboration and service excellence, and serves as a subject matter expert on quality and patient safety issues. The manager also oversees operational budgets, accreditation and regulatory compliance, and the daily work of local performance improvement and patient safety specialists.

Requirements

Bachelor’s degree in Nursing or a related clinical area.
Healthcare Quality Certification (CPHQ) required or obtained within twelve months of employment.
At least three years of acute hospital-based experience.
At least one year of supervisory experience.
Working knowledge of robust process improvement techniques.
Knowledge of leading practices in clinical care and regulatory and accreditation requirements.
Self-motivated, with proven communication skills and an assertive approach.
Demonstrated ability to work effectively with physicians.
Ability to collaborate with health care professionals at all levels to achieve established goals and improve quality outcomes.

Nice To Haves

One year of experience in clinical performance improvement or another quality management program.

Responsibilities

Manage components of the hospital quality and patient safety program.
Identify improvement opportunities based on evidence-based clinical practices and statistical analysis of current practice patterns.
Manage collection, aggregation, and dissemination of clinical quality and patient safety data within the hospital.
Collaborate with hospital leadership to manage and monitor outcome measures.
Promote a culture of patient safety and implement high-reliability practices.
Collaborate with system and regional leadership to implement patient safety alerts, prompts, and tools.
Manage local performance improvement and patient safety specialists and implement systems for knowledge transfer and operational efficiency.
Facilitate and manage short- and long-term quality and patient safety improvement projects.
Promote communication and collaboration among stakeholders in quality and patient safety strategies.
Collaborate with system, regional, and hospital leadership to implement education on quality and patient safety principles for physicians, managers, staff, patients, and families.
Coordinate ongoing accreditation and regulatory compliance within the hospital with JCAHO, CMS, and TDH.
Manage the day-to-day hospital quality and patient safety operational budget, ensuring revenue, expenses, contribution margin, and FTEs meet or exceed budget.
Prepare and submit budgets and related reports, forecast and project expenses, take corrective action for negative variances, and identify and propose capital budget items.
Ensure safe care for patients, staff, and visitors and adhere to organizational policies, procedures, and standards within budgetary specifications.
Promote professional growth and development, meet mandatory and continuing education and competency requirements, support department goals, and serve as a preceptor, mentor, and resource to less experienced staff.
Model service standards by providing safe, caring, personalized, and efficient experiences to patients and colleagues.
Perform other duties as assigned.