We are honored to share that all seven of our eligible hospitals have been named top performers in the 2025 Bernard A. Birnbaum, MD, Quality Leadership Rankings by Vizient Inc., a trusted national benchmark for hospital performance.
This year, five of our hospitals ranked in the top five of their …
Performance Improvement Specialist - Part-time - Neuroscience
Location:
Houston Methodist Sugar Land Hospital
16605 Southwest Freeway, Sugar Land TX, 77479
16605 Southwest Freeway, Sugar Land TX, 77479
- Job Ref:
- 2025-76783
- Talent Area:
- Professional
- Job Shift:
- Day
- Job Type:
- Part Time
At Houston Methodist, the Performance Improvement Specialist is responsible for the development of performance improvement/patient safety initiatives. Promotes organization wide understanding of the overall quality and patient safety program and culture. Facilitates timely and effective resolutions of patient care issues. Serves as a resource to all levels of the organization relative to quality improvement activities, conducting or providing education as requested by staff or leadership. Coordinates teams as needed to drive change towards desired outcomes using appropriate performance improvement methodologies.
FLSA STATUS
Exempt
QUALIFICATIONS
EDUCATION
EXPERIENCE
LICENSES AND CERTIFICATIONS
Required
SKILLS AND ABILITIES
ESSENTIAL FUNCTIONS
PEOPLE ESSENTIAL FUNCTIONS
SERVICE ESSENTIAL FUNCTIONS
QUALITY/SAFETY ESSENTIAL FUNCTIONS
FINANCE ESSENTIAL FUNCTIONS
GROWTH/INNOVATION ESSENTIAL FUNCTIONS
SUPPLEMENTAL REQUIREMENTS
Exempt
QUALIFICATIONS
EDUCATION
- Bachelor of Science or higher degree in Nursing required
EXPERIENCE
- Three years of experience in a hospital or outpatient clinical role
- One year of experience in a quality management and/or patient safety, risk management, decision support or similar information analysis role
LICENSES AND CERTIFICATIONS
Required
- RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency)
- CPHQ - Certified Professional in Healthcare Quality (NAHQ) or
- CPPS - Certified Professional in Patient Safety (IHI) or
- or other related professional certification preferred
SKILLS AND ABILITIES
- Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
- Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
- Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
- Knowledge of statistical analysis techniques and software
- Knowledge of performance improvement methodologies and principles
- Knowledge of the principles of patient safety
- Knowledge of accreditation and regulatory agencies requirements for performance improvement and patient safety
- Ability to learn and apply use of databases for aggregation of data for analysis
- Strong leadership qualities (task completion, motivation)
- Ability to independently analyze and solve problems
ESSENTIAL FUNCTIONS
PEOPLE ESSENTIAL FUNCTIONS
- Collaborates with Education on instructing/informing staff on new or revised quality programs or plans, regulatory and accreditation standards, and/or performance improvement processes as applicable.
- Collaborates in an interdisciplinary manner on hospital-wide patient safety, performance improvement, and data management/analysis functions to maximize outcomes.
SERVICE ESSENTIAL FUNCTIONS
- Leads accreditation readiness initiatives. Participates in regulatory and accreditation surveys.
- Serves as a resource for basic data analysis. Develops summary reports and assists with presentation of findings to various audiences.
- Coordinates the agenda and meeting materials for the quality and patient safety committees of the hospital for assigned areas.
QUALITY/SAFETY ESSENTIAL FUNCTIONS
- Maintains all programs to ensure compliance to accreditation standards and regulatory agency requirements.
- Abstracts pertinent information and enters into department databases using standardized methods and processes. Routinely performs discrepancy management activities to maintain data integrity. Presents meaningful reports and analysis with measurement description, statistical information, and benchmarking information. Reports data to external agencies as needed.
- Concurrently reviews and analyzes inpatient records to ensure that compliance to quality indicators is met.
- Provides basic analyses of hospital performance against patient safety, quality and outcomes measures.
- Utilizes results from performance improvement activities to identify and prioritize areas of focus for improvement. Evaluates and provides input on the effectiveness of performance improvement programs.
- Supports improvement efforts for potential or actual quality of care/risk issues including participation/facilitation of Root Cause Analysis (RCA), Failure Modes Effects Analysis (FMEA), or event review as needed. Supports leadership and staff with the development and implementation of process changes. Summarizes events and presents findings as needed. Facilitates systems’ design to hardwire patient safety processes.
- Conducts record review for performance improvement, peer review, patient safety, risk management and other projects.
FINANCE ESSENTIAL FUNCTIONS
- Proactively identifies quality and safety improvement opportunities through analysis of internal and external data, to include federal incentive programs as applicable.
GROWTH/INNOVATION ESSENTIAL FUNCTIONS
- Designs, develops, and implements project plans related to strategic quality and safety initiatives. Manages reporting of these projects/measures to internal departments/committees and/or outside agencies, as needed. Provides oversight for these projects to ensure desirable outcomes are met.
SUPPLEMENTAL REQUIREMENTS
- WORK ATTIRE
- Uniform: No
- Scrubs: No
- Business professional: Yes
- Other (department approved): No
- On Call* No
- May require travel within the Houston Metropolitan area Yes
- May require travel outside Houston Metropolitan area Yes
ON-CALL*
*Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Events, etc) regardless of selection below.
TRAVEL**
**Travel specifications may vary by department**
Company Profile:
Houston Methodist Sugar Land Hospital is committed to leading medicine by delivering the Houston Methodist standard of unparalleled quality, safety, service and innovation to patients in Fort Bend County and surrounding areas. Houston Methodist Sugar Land offers access to the most innovative care available, including comprehensive cancer care; neuroscience and spine care; orthopedics and sports medicine; heart and vascular care; women’s services; childbirth center with level III NICU; bariatric and digestive care; and advanced imaging — all backed by our focus on healing people today and offering hope for tomorrow.
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