Manager, Hospital Quality, Enterprise Quality and Patient Safety

Memorialhermann; Texas; On-site; USD 110,000 - 140,000; Full time

Job summary

Memorial Hermann seeks a Hospital Quality Manager to lead the hospital quality and patient safety program, driving evidence-based improvement and high reliability across processes. The role involves supervising quality staff, educating leaders and clinicians, and ensuring compliance with regulatory standards.

The incumbent will oversee data reporting, performance improvement projects, and collaboration with physicians to advance patient outcomes and cost containment within a large hospital

Qualifications

• Bachelor degree required in nursing or related clinical field.
• CPHQ certification required or expected within 12 months of employment.
• Minimum three years hospital-based experience with supervisory responsibilities.

Responsibilities

• Manage hospital quality and patient safety program components.
• Identify quality and patient safety improvement opportunities using evidence-based practices and data.
• Oversee data collection, aggregation, and dissemination of quality metrics.
• Collaborate with leadership to monitor outcomes measures and targets.
• Promote patient safety culture and high-reliability principles hospital-wide.
• Coordinate accreditation and regulatory compliance (JCAHO, CMS, TDH).
• Direct daily quality and patient safety operations and budget management.

Skills

Supervisory leadership

Quality improvement

Robust process improvement

High reliability practices

Regulatory & accreditation knowledge

Budget management

Communication skills

Collaboration with physicians

Data collection & analysis

Education

Bachelor's degree in Nursing or related clinical area

Healthcare Quality Certification (CPHQ)

Job description

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