Director of Quality
Job Ref # 30899
Location: Nassau Bay, TX
Category: Other

Work Shift: DAY

Work Week: M - F

  • 178 beds, 224 physicians and over 800 staff members
  • 7 Sports Medicine clinics

Job Summary


Responsible for management, oversight, and coordination of the Performance Improvement Department to identify, analyze, and guide improvements in patient care and service delivery to include, but not limited to, risk management, infection control, patient satisfaction, quality control, medical peer review, sentinel event management, quality issues, compliance, and benchmarking studies, so that Hospital, Network, Medical Staff, and regulatory agency requirements are met. Additionally, serves as a resource and facilitator for hospital wide and system wide performance improvement activities. Collaborates with Senior Management to develop and analyze meaningful outcomes reporting to improve care delivery. Communicates effectively with all levels of staff, physicians, and external groups including regulators, payors, and accrediting bodies.


1. Develops and oversees Quality, Performance Improvement, Core Measures, Goals, Leapfrog, Infection Control, and Risk Management programs. Participates in and provides support for network wide committees, projects, and task forces.

2. Leads and directs fiscal budget development, oversight, and reporting for the Department of Performance Improvement.

3. Directs the departmental human resources function including but not limited to hiring, firing, mentoring and coaching, performance and compensation reviews, and employee relations for the Department of Performance Improvement in accordance with hospital and network policies and procedures. Responsible for planning and organizing departmental activities. 

4. Maintains all programs to ensure compliance to JCAHO accreditation standards and regulatory agency requirements. Disseminates data as appropriate, prepares and presents reports for Board as required. Participates in regulatory surveys.   Facilitates and acts as a resource regarding compliance with JCAHO standards   and the Medicare Conditions of Participation.

5. Serves as hospital patient safety officer. Supports hospital-wide patient safety, performance improvement, and data management/analysis functions through participation and support of interdisciplinary and intradisciplinary activities designed to maximize outcomes utilizing minimum resources. Ensures departmental employee compliance with the hospital patient safety program.  

6. Functions as team facilitator and/or leader for RCA, FMEA, and other complex problem solving groups.

7. In coordination with Administration, Risk Management, Nursing Services, and Medical Staff Services, participates in conducting and reporting medical and nursing peer review activities. Facilitates completion of activities as required by Medical Staff peer review program. 

8. Facilitates and acts as primary source regarding compliance with patient complaints. 

9. 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 and Service Pride Program into operational milieu. Exhibits expected behaviors for patient and visitor interactions as outlined in the Service Pride program.

10. Performs other duties as assigned in a professional, cooperative, and responsible manner reflecting positively on the department leadership noted in the Methodist St. John Hospital organizational chart.


Graduate of an Accredited School of Nursing or Bachelor degree in a healthcare related field. Master`s preferred. Nursing candidates must have valid Texas license.


5 - 7 years hospital management experience required. 2 years experience hospital Quality / Performance Improvement. Demonstrated experience in understanding and executing performance improvement concepts and activities.


Certification as a Professional in Healthcare Quality.  For Registered Nurses: Current licensure to practice in the State of Texas. For HIM professionals: Registered Health Information Administrator. CERTIFICATES, LICENSES AND REGISTRATIONS REQUIRED: N/A  WORKING : Normal office setting.  Some travel 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.

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:

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