Quality and Patient Safety Program Manager

St. Luke's Health–Sugar Land Hospital is a 100 bed facility serving residents of Fort Bend County and Southwest Houston. Our Family Birthing Center provides exceptional care in a spa-like setting, creating a VIP (Very Important Pregnancy) experience for growing families. Since opening in 2008, our dedicated team of physicians, nurses and support staff has proudly delivered expert, compassionate care to our community. Our services range from heart care and neuroscience to robotic surgery.

As our Quality/Patient Safety Program Manager you will support, coordinate, and facilitate the quality management (QM), patient safety (PS) and regulatory performance improvement (PI) activities for the hospital and medical staff. This role also serves as a resource to employees, management, nursing directors, senior management, councils, physicians and teams on quality management activities and will handle patient sensitive and confidential hospital information.

Every day you will assist in the design, planning, implementation and coordination of Quality Management, Patient Safety and Performance Improvement activities for assigned hospital and medical staff departments, committees, divisions, service lines and functions. You will proactively coordinates and facilitates performance improvement teams to support key initiatives, including but not limited to, activities focused on clinical quality improvement, patient safety and risk reduction, patient experience, efficiency, FMEAS, root cause analyses and medical staff improvement (e.g. case review for peer review, OPPE, FPPE).

In this integral role you will ensure compliance with CMS HIQRP/HOQRP, TJC, Leapfrog, etc., data collection and reporting of process and outcome measures, and maintain current knowledge of accreditation and licensing requirements and must be a resource to staff on these regulations in order to improve management of outcomes and ensure compliance. 

• Licensed Registered Nurse, Licensed Clinical Pharmacist, or other Licensed Clinical Staff and three (3) years clinical experience in an acute care setting
• Must be able to perform case reviews for medical staff peer review and medical and/or surgical Registry Abstraction
• One (1) year healthcare-related quality management/performance improvement experience (e.g., chart audit, PI team member, etc.)
• Current state license in a clinical field in state of practice.
• Certified Professional in Healthcare Quality (CPHQ), or Healthcare Quality and Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment is required.