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RN Performance Improvement Coordinator

Job Ref: 27229

Talent Area: RN - Performance Improvement/Quality

Houston Methodist St. John Hospital
Nassau Bay, TX 77058

Area/Department: Qual Care Mgmt

Employment Type: Regular

Job Type: Full-Time

Organization: Houston Methodist

Work Shift: DAY

Work Week: M - F

Company Profile

Houston Methodist St. John Hospital is one of the newest members of the Houston Methodist family—extending its healing mission to the many communities in the Greater Bay Area.  Located on the shores of Clear Lake across from the Johnson Space Center, the facility offers advanced medical and surgical care by team members called to serve with excellence and compassion:

  • 137 beds, 224 physicians and over 800 staff members
  • 6 Sports Medicine clinics, 2 Outpatient Laboratory & Imaging clinics
  • Awarded Top Performer™ by The Joint Commission
  • Clear Lake’s only “A” rated hospital by The Leapfrog Group™


Job Summary


Works to achieve high quality, cost-effective healthcare for the patients served at the hospital. Provides leadership and management of the patient safety and performance improvement programs. Proactively identifies target areas for improvement and assists hospital leaders and physicians in developing strategies to improve performance in quality and patient safety. Utilizes basic and advanced analyses techniques to identify areas for improvement related to quality, patient safety, operational, financial, and other performance and external benchmarking measures. Provides advanced logistical and technical support for the hospital external benchmarking initiatives. Assures the requirements for patient safety and quality management set by JCAHO and CMS are met.


1. Responsible for coordination and implementation of the Hospital quality and patient safety programs including the development of program/s goals, objectives, timelines, data gathering, analysis, and reporting. Develops summary reports and assists with presentation of findings to various audiences. Assures the program/s meet the requirements set by JCAHO and CMS.  2. Provides basic and advanced analyses of hospital performance against patient safety, quality and outcomes measures. Proactively identifies quality and safety improvement opportunities through analysis of internal and external data. Serves as system-wide resource for advanced data analysis. Supports the hospital external benchmarking initiatives. Provides timely and accurate reports of these activities to physicians and hospital leaders.  3. Designs, develops, and implements project plans related to the Core Measures Projects and other strategic quality and safety initiatives. Manages reporting of these projects/measures to outside agencies, as needed. Provides oversight for these projects to ensure desirable outcomes are met.  4. Develops and presents education and training regarding the system-based causes of medical errors and communicates literature-based ideas regarding effective patient safety strategies to the organization. Develops and presents education and training on performance improvement tools and techniques, methods for measurement, analysis and reporting.  5. Provides a system for tracking of quality indicators for departmental and committee performance improvement and other performance improvement reports.  6. Responsible for directing and managing the peer review program and process. Conducts record review for performance improvement, peer review, patient safety and other projects.  7. Investigates (along with risk management) patient safety issues within the facility. Identifies medical errors in which an RCA or an IA is needed. Conducts and/or oversees the performance of RCA`s or IA`s. Develops and presents the report of findings, actions and follow-up.  8. Responsible for coordination of the agenda and meeting materials for the quality and patient safety committees of the Hospital.  9. Demonstrates the components of the I CARE values statement (Integrity, Compassion, Accountability, Respect, Excellence). 10. Demonstrates ServicePRIDE standards ( Smile and make eye contact; greet each patient and visitor; seek out patient and visitor contact; displays appropriate body language at all times; take 5 minutes each day to go above and beyond for one patient or visitor; honor diversity; thanks every customer.) 11. Follows all safety rules while on the job. Reports accidents promptly and corrects minor safety hazards. 12. Perform other duties as assigned.

EDUCATION REQUIREMENTS: Graduate of an accredited Nursing School Bachelor`s degree preferred Masters degree or advanced training in patient safety and quality management is preferred.


3 years of experience in a quality management and/or patient safety, decision support or similar information analysis role.  Education may be substituted for 1 year of experience.

CERTIFICATES, LICENSES AND REGISTRATIONS REQUIRED:  Registered Nurse with current Texas license Certified Professional in Healthcare Quality (Preferred)  

CERTIFICATES, LICENSES AND REGISTRATIONS REQUIRED: Must be licensed or eligible for licensure to practice pharmacy in the State of Texas  Must maintain continuing education credits to maintain professional licensure  Must have the training for aseptic technique and sterile product preparation as required by law.  Must satisfy horizontal and/or vertical hood certification requirements.  Must maintain CPR certification. May obtain within 30 days of hire. 

WORKING : Must be familiar with the Body Substance Isolation and Blood Borne Pathogen guidelines.  Must be familiar with the OSHA guidelines for the safe handling of cytotoxic and hazardous substances.  Must satisfy the Hazard Communications Act requirements.  Must be able to work in an environment with high levels of potential latex exposure.  Must be able to use standard office and pharmaceutical equipment. Rotating evening and weekends may be required; on-call may be required.

Equal Employment Opportunity

Houston Methodist is an Equal Opportunity Employer.

Equal employment opportunity is a sound and just concept to which Houston Methodist is firmly bound. Houston Methodist will not engage in discrimination against or harassment of any person employed or seeking employment with Houston Methodist on the basis of  race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, status as a protected veteran or other characteristics protected by law.

VEVRAA Federal Contractor – priority referral Protected Veterans requested.