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Performance Improvement Coordinator (RN)

Job Ref: 27382

Talent Area: RN - Performance Improvement/Quality

Houston Methodist San Jacinto Hospital
Baytown, TX 77521

Area/Department: Performance Improvement

Employment Type: Regular

Job Type: Full-Time

Organization: Houston Methodist

Work Shift: 8:00 a.m. - 5:00 p.m.

Work Week: M - F

Company Profile

Houston Methodist San Jacinto Hospital, located 35 miles southeast of Houston, is the area's only full-service hospital offering specialized medical care for patients at every stage in life. This 392 licensed bed hospital with 18 operating rooms, and over 1,400 employees, brings Medical Center excellence and quality care close to East Harris and surrounding counties.

Job Summary

The Performance Improvement (PI) Coordinator works directly with hospital employees and members of the Medical Staff to achieve superior quality of care as measured by compliance to quality indicators. Performs concurrent chart review of identified cases using established quality indicators and actively intervenes to meet established standards. Coordinates reporting results of quality findings to appropriate databases and reports risk management concerns to the department director. Assists with other audit activities including, but not limited to, new external databases, special studies, and internal operation audits. The Performance Improvement (PI) Coordinator facilitates committees, work groups, and special projects as assigned. In addition, the PI Coordinator supports and/or serves to back-up department functions including, but not limited to, regulatory compliance, quality improvement and patient safety. 



  1. Projects a positive customer service image and responds effectively when dealing with patients, family members, staff, physician, and other departments by integrating I CARE values into operational milieu. (5%)


  1. Exhibits expected behaviors for patient and visitor interactions as outlined in the Service Pride program. Demonstrates ability to work effectively with physicians, hospital and departmental staff.  (5%)


  1. Concurrently reviews and analyzes inpatient record to ensure that compliance to quality indicators are met. 
  2. Intervenes and takes appropriate action to foster real-time compliance to core measures and other performance measures associated with certification programs and other regulatory, national, regional or locally- sponsored quality programs. Interventions to promote compliance may include discussion, and/or collaboration with physicians, nurses, other healthcare personnel and/or patients.
  3. Assists in the development and implementation of quality and risk measurement processes to capture accurate and concise information that can be used for a quality improvement. Demonstrates an ability to learn and adapt to changes in regulatory requirements, criteria revisions, and departmental needs. Assists with intradepartmental data collection associated with various external, internal, and administrative audits and/or studies. Serves as resources to staff and management for department specific quality program development.  
  4. Supports hospital-wide patient safety, performance improvement, and data management and analysis functions through participation and support of interdisciplinary and interdisciplinary activities to maximize outcomes utilizing minimum resources. Able to work with hospital employees and Medical Staff towards improving internal and external quality indicators.
  5. Assists in the implementation of regulatory standards as part of processes and quality improvement across the continuum of care.  Demonstrates an ability to learn and adapt to changes in regulatory requirements, criteria revisions, and departmental needs. Assists with development and revision of policies and procedures to meet current practice standards.  Assists with ongoing regulatory compliance. 
  6. Supports the peer review process through appropriate selection of cases for medical staff peer review using defined criteria or referral.  Presents cases to Peer Review members and ensures timely resolution of patient care issues.  Follows peer review policy/procedures to document action at all process steps in peer review process.  Aggregates physician profile data to support the reappointment process as requested.  Identifies process issues and makes referral to medical staff and/or quality leadership for resolution. Drafts letters in conjunction with the committee chair; maintains committee records. 
  7. Supports improvement efforts for potential or actual quality of care 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.  Conducts evaluation of effectiveness of initiatives and presents findings as needed.  Facilitates systems’ design to hardwire patient safety processes.  


  1. Ensures the department facilities are maintained in proper condition and that basic environmental safety standards are met. Ensures departmental employee compliance with the hospital safety program.
  2. Utilizes supplies and resources in an appropriate manner demonstrating good stewardship of all resources. 


  1. Exercises sound clinical judgment, discretion and initiative when performing medical record audits. Performs all work duties and responsibilities with minimal supervision. Communicates identified quality or risk issues through departmental and hospital chain-of-command. 



Graduation from an accredited School of Nursing, BSN preferred.  Current license to practice as a Registered Nurse in the State of Texas.



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.  Knowledge of process improvement strategies and statistical methods preferred. Experience with data abstraction preferred.  Knowledgeable regarding federal and state regulatory standards preferred.



Current license to practice as an RN in the State of Texas.

Certified Professional in Healthcare Quality (CPHQ) preferred.



  • Knowledge of quality review and principles required.
  • Good oral and written communication skills.
  • Able to interact professionally with all levels of personnel, management and physicians. 
  • Time management and prioritization skills. 
  • Flexible and able to deal with change. 
  • Able to flex schedule to meet needs of the job if required.
  • Ability to travel to other Houston Methodist locations and other training sites

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.