Quality Manager

Townsen Memorial Hospital•Humble, TX

21d

About The Position

Townsen Memorial Health System is seeking a full-time Manager of Quality to oversee the operational management of Quality Coordinators and the Infection Preventionist. The role ensures effective facility-level execution of Quality Assurance (QA), Performance Improvement (PI), and Infection Control (IC) activities, manages daily departmental operations, supports staff development, and ensures accurate data collection and reporting. The Manager facilitates quality initiatives across departments and reports to the Director of Quality for direction and escalation of regulatory or compliance risks. The position oversees quality and infection-control activities, including audits, surveillance, data analysis, reporting, survey readiness, education, employee health requirements, and corrective action tracking. It collaborates with department leaders and clinical staff, serves as a resource across departments, and presents findings and recommendations to leadership and designated committees. Employment is contingent on successful completion of a background check and drug screening. Townsen Memorial Hospital is an accredited network of facilities focused on emergency care, outpatient surgery, and diagnostics and imaging. Its stated mission is to provide compassionate, evidence-based patient care, and its values include diversity, dignity, and inclusiveness. Compensation is determined based on the applicant’s education, experience, knowledge, skills, abilities, internal equity, and market data.

Requirements

Five years of experience in healthcare quality in an acute-care hospital setting.
Registered Nurse or Licensed Vocational Nurse license in the State of Texas.
Basic Life Support (BLS) certification.
Knowledge of healthcare regulations, accreditation standards, and infection-control requirements.
Strong organizational, analytical, and problem-solving skills.
Ability to collect, analyze, and report quality and performance data.
Effective verbal, written, and interpersonal communication skills.
Ability to manage competing priorities in a fast-paced healthcare environment.
Attention to detail and commitment to accuracy.
Ability to work independently and collaborate effectively with leadership and staff.
Proficiency with electronic health records, quality-reporting systems, and Microsoft Office applications.
Ability to maintain professionalism, composure, and sound judgment in high-stress situations.
Documented training and demonstrated competency in infection prevention and performance-improvement methodologies.

Responsibilities

Directly supervise Quality Coordinators and the Infection Preventionist, providing guidance, oversight, and performance management.
Assign and monitor workloads to ensure completion of audits, surveillance, data abstraction, and reporting.
Oversee the facility’s QA, PI, and IC programs to ensure operational effectiveness.
Ensure infection surveillance is conducted consistently and findings are appropriately communicated.
Review audit results and performance data with staff, and ensure follow-up actions are implemented and tracked to completion.
Participate in root cause analyses and ensure assigned corrective actions are carried out and monitored.
Ensure timely and accurate collection, validation, and submission of quality and infection-control data as directed by the Director of Quality.
Support survey readiness by coordinating documentation, audit findings, and action plans.
Implement QA, PI, and IC policies and procedures and monitor departmental adherence.
Escalate identified regulatory or compliance risks to the Director of Quality.
Collect, analyze, trend, and report quality indicators, infection-control metrics, and performance-improvement data.
Develop and maintain tracking tools, dashboards, and action plans to support measurable improvement.
Present findings and recommendations to leadership, committees, MEC, and the Board as assigned.
Conduct routine and focused audits to validate compliance with standards of care and organizational policy.
Develop and deliver education related to quality improvement, infection prevention, and regulatory compliance.
Ensure staff complete required QA, PI, and IC education and competency validation.
Provide real-time coaching to reinforce best practices and regulatory expectations.
Oversee and track employee health requirements, including screenings, immunizations, and required documentation.
Ensure employee health records are complete, accurate, and maintained in accordance with regulatory standards.
Partner with department leaders and clinical staff to implement performance-improvement initiatives and corrective-action plans.
Serve as a resource for quality and infection-control standards across departments.
Educate patients and families about infection prevention and quality-related practices as appropriate.
Maintain accurate, timely, and compliant documentation in accordance with organizational policy and privacy regulations.
Participate in assigned quality, safety, and performance-improvement committees and meetings.
Perform other related tasks as needed.