Quality-Patient Safety Program Manager

St. Luke's Health–The Vintage Hospital provides high-quality, compassionate care for residents of the Willowbrook, Champions, and Tomball areas of Northwest Houston. With the resources of the St. Luke’s Health system, we are able to deliver the most advanced care available to our Northwest Houston community. The Vintage Hospital offers the latest in diagnostic and surgical expertise, including heart care, women’s health, and orthopedics.

The Quality/Patient Safety Program Manager supports, coordinates, and facilitates quality management (QM), patient safety (PS), and regulatory performance improvement (PI) activities for the hospital and medical staff. This role serves as a key resource to employees, leadership, nursing directors, senior management, councils, physicians, and interdisciplinary teams on quality management initiatives. The position requires handling sensitive and confidential patient and hospital information with discretion.

• Support the design, planning, implementation, and coordination of Quality Management, Patient Safety, and Performance Improvement activities across assigned hospital and medical staff departments, committees, service lines, and functions

• Proactively coordinate and facilitate performance improvement teams to support key initiatives, including but not limited to:

  • Clinical quality improvement

  • Patient safety and risk reduction

  • Patient experience

  • Operational efficiency

  • Failure Mode and Effects Analyses (FMEAs)

  • Root cause analyses

  • Medical staff performance improvement activities such as peer review, OPPE, and FPPE

• Serve as a subject matter resource for quality management activities to staff, leadership, physicians, and interdisciplinary teams

• Ensure compliance with regulatory and quality reporting requirements, including CMS HIQRP/HOQRP, The Joint Commission (TJC), Leapfrog, and other applicable programs

• Play an integral role in the collection, abstraction, validation, and reporting of process and outcome quality measures

Required Education and Experience

• Licensed Registered Nurse, Licensed Clinical Pharmacist, or other licensed clinical staff with three (3) years of clinical experience in an acute care setting

• Ability to perform case reviews for medical staff peer review and medical and/or surgical registry abstraction

• One (1) year of healthcare-related quality management or performance improvement experience (e.g., chart audits, PI team member participation)

Required Licensure and Certifications

• Current, unrestricted state license in a clinical field in the state of practice

• Certified Professional in Healthcare Quality (CPHQ), Healthcare Quality and Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) required within two (2) years of employment.