Manager, Hospital Quality, Enterprise Quality and Patient Safety

At Memorial Hermann, we pursue a common goal of delivering high quality, efficient care while creating exceptional experiences for every member of our community. When we say every member of our community, that includes our employees. We know that when our employees feel cared for, heard and valued, they are inspired to create moments that exceed expectations, while prioritizing safety, compassion, personalization and efficiency. If you want to advance your career and contribute to our vision of creating healthier communities, now and for generations to come, we want you to be a part of our team.

Job Summary

The Hospital Quality Manager will manage the hospital quality and patient safety program. The manager will supervise others within the hospital in clinical robust process improvement supporting evidence based practices, the reduction of medical/health care errors and other factors that contribute to unintended adverse outcomes. The manager will provide supervision for robust process improvement projects ensuring high reliability methods, quality measures monitoring and ongoing regulatory compliance and readiness. The manager will assist in educating leadership, physicians, and staff on high reliability methodologies including system-based causes for medical error within a hospital. The Hospital Quality Manager will work closely with hospital leadership to optimize hospital strategic goals and objectives. The manager supervises the collection, analysis and reporting of quality and patient safety data within a hospital in relation to cost containment, performance improvement and outcomes. The manager is accountable for coordinating the reporting of hospital improvement activities addressed at different levels including Monthly Operating Reviews and Quality Committees. The manager promotes interdisciplinary collaboration; fosters team work and champions service excellence throughout a hospital. The manager serves as a resource and subject matter expert to proactively address quality and patient safety issues.

Job Description

Minimum Qualifications

Education: Bachelors Degree in Nursing or related clinical area required

Licenses/Certifications: Healthcare Quality Certification (CPHQ) required or within twelve months of employment

Experience / Knowledge / Skills:

Minimum three (3) years acute hospital-based experience

One (1) year supervisory experience

One (1) year experience preferred in clinical performance improvement or other quality management program

Working knowledge of robust process improvement techniques

Knowledge of leading practice in clinical care and regulatory and accreditation requirements

Self-motivated, proven communication skills, assertive

Demonstrated effective working relationship with physicians

Ability to work collaboratively with health care professionals at all levels to achieve established goals and improve quality outcomes

Directs and manages the day to day regional quality and patient safety operational budget. Assures that revenue, expenses, contribution margin and FTEs meet or exceed budget; prepares and submits budget and related reports; forecasts and accurately projects expenses; takes corrective action to address negative variances; identifies and proposes capital budget items appropriately.

Principal Accountabilities

Manages components of the hospital quality and patient safety program.

Assists in identifying quality and patient safety improvement opportunities based on evidence based clinical practices and statistical analysis of current practice patterns.

Manages clinical quality and patient safety data collection, aggregation, and dissemination within the hospital, specific to clinical quality and patient safety.

Collaborates with hospital leadership to manage and monitor outcomes measures within the hospital.

Promotes a culture of patient safety and implementation of high reliability practices within a hospital.

Collaborates with system and regional leadership to implement patient safety alerts, prompts and tools within a hospital.

Manages local performance improvement and patient safety specialists in their daily quality and patient safety operations, and implements systems for optimal knowledge transfer and efficiency within the hospital.

Facilitates and manages short term and long term quality and patient safety robust process improvement projects to continuously improve the quality and patient safety program within the hospital.

Promotes communication and collaboration between all stakeholders in quality and patient safety strategies.

Collaborates with system, regional and hospital leadership to implement the education program for physicians, managers, staff, patients and families pertaining to quality and patient safety principles.

Coordinates accreditation and regulatory continuous compliance within the hospital with JCAHO, CMS, and TDH.

Manages the day to day hospital quality and patient safety operational budget. Assures that revenue, expenses, contribution margin and FTEs meet or exceed budget.

Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.

Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.

Demonstrates commitment to caring for every member of our community by creating compassionate and personalized experiences. Models Memorial Hermann’s service standards by providing safe, caring, personalized and efficient experiences to patients and colleagues.

Other duties as assigned.