Director Quality
Job Ref # 31340
Location: Houston, TX
Category: Administrative Management

Work Shift: DAY

Work Week: M - F

Job Summary

The Director of Quality reports to the Vice President of Quality Operations and Patient Safety and is responsible for the development, direction and effective implementation of a comprehensive hospital-wide infection control program, performance improvement, peer review program, outcomes management ,external reporting and patient safety systems.  Key performance components include:
1. Clinical process improvement and team management across all HMH depts.
2. Lead all CMPI direction in collaboration with VP, CQO and AQOs.
3. Expertise in Data/information management, protection, presentation and benchmarking.
4. DNV and other regulatory compliance for quality of care.
5. Registry oversite, budgeting and staffing for quality improvement and operational efficiencies.
6. Support departmental quality resources as entity expert and partner.
7. Participate with system quality leadership to gain competency and effectiveness in organization wide initiatives as prescribed in strategic plan.
8. Organizational leadership, change management and culture education as key components of all PI and Patient Safety duties and deliverables.

Refer to departmental Scope of Service and Provision of Care plans, as applicable, for description of primary age groups and populations served by this job for the respective HM entity.


I. Provide personalized care and service by consistently demonstrating our I CARE values:

INTEGRITY: We are honest and ethical in all we say and do.
COMPASSION: We embrace the whole person including emotional, ethical, physical, and spiritual needs.
ACCOUNTABILITY: We hold ourselves accountable for all our actions.
RESPECT: We treat every individual as a person of worth, dignity, and value.
EXCELLENCE: We strive to be the best at what we do and a model for others to emulate. 

II. Focuses on patient/customer safety
III. Delivers personalized service using HM Service Standards
IV. Provides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET, Managing Up, Key Words)


PEOPLE -20 %
1. Promotes a satisfied and competent employee work environment through establishing a climate for growth and challenge, doing timely performance appraisals, providing development and mentoring of manager and staff (EF)
2. Sets priorities and goals in consultation with senior management.  Gives direction and guidance to departmental staff as necessary (EF)
3. Proactive and effective in developing and maintaining collaborative relationships with physicians, hospital leaders and their employees.  Participates in making recommendations for improving working relationships in the work area.  Continue development and deployment of physician leadership model in collaboration with physician executives (EF)

1. Directs, delegates and oversees work efforts as appropriate to insure the best possible delivery of service and high customer/patient satisfaction (EF)
2. Provide direction for information management support to CMPI and Patient Safety activities (EF)
3. Lead hospital-wide effort to educate organization regarding Performance Improvement philosophy, methodology, tools, techniques and emerging trends.  Provide organizational leadership in clinical process improvement (EF)
4. Act as consultant to all departments/divisions and medical staff in development of Performance Improvement plans, initiatives and measurement strategies in concert with the Houston Methodist Hospital Care Management/Performance Improvement (CMPI) program objectives (EF)

1. Prepare summary reports of key Performance Improvement/Patient Safety activities, actions, outcomes and trends for appropriate committees (EF)
2. Serve as central repository for organization-wide Performance Improvement and Patient Safety activities and results (EF)
3. Develop and continuously improve the hospital-wide Performance Improvement/ Patient Safety program. Collaborate with Medical Staff Quality Management (peer review) activities to ensure program effectiveness, goal achievements, contemporary state of the art practices, and regulatory compliance (EF)
4. Develops, implements, and monitors The Methodist Hospital Safety Management Program, Infection Prevention and Control Program  based on evaluation of organizational expertise, evidence based care,  applicable law, regulations, best practices and ensures the hospital¿s compliance with Joint Commission (JC), federal, state and local requirements. (EF)

1. Plans, budgets and organizes department to accomplish operational and strategic objectives and stays within budget (EF)
2. Develop PI activities that effective reduce exposure to pay for performance penalties. (EF)

1. Seeks out best demonstrated practice and applies learnings to current CMPI processes.(EF)
2. Publishes/presents to professional organizations as appropriate to enhance best practices and knowledge share within healthcare industry, enhancing quality reputation of HM. 

This job description is not intended to be all inclusive; the employee will also perform other reasonably related business/job duties as assigned.  Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.

Graduate of accredited Bachelor's degree nursing program; Masters Degree in Nursing, or relevant Healthcare degree with experience in Healthcare Quality and Outcomes Management.

 At least 10 years of total relevant experience including at least:
 Three to five years clinical hospital/hospital operations experience.
 Five or more years hospital Performance Improvement experience.
 Three or more years management experience in directing a complex hospital-wide Performance Improvement program.
 Experience with regulatory surveys preparation and coordination

 Certified Professional in Healthcare Quality preferred.  Six Sigma certification desired.
 Current Texas RN license

 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.
 Advanced knowledge of the performance improvement philosophy, methodology, tools and techniques.
 Working knowledge of all regulatory compliance impacting Performance Improvement programs.
 Advanced knowledge of management principles, processes and procedures.
 Excellent interpersonal relationship skills at all levels of the organization.
 Verbal and written communication skills.
 Skill in planning, organizing and delegating departmental responsibilities.
 Skill in coaching, counseling, developing others and team facilitation.
 Ability to analyze and solve problems.
 Database management and systems development.

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

Since its founding in 1919, Houston Methodist Hospital has earned worldwide recognition. Houston Methodist Hospital is affiliated with the Weill Medical College of Cornell University and New York-Presbyterian Hospital, one of the nation's leading centers for medical education and research.  Houston Methodist is consistently ranked in U.S. News & World Report’s “Best Hospital” list and was recently named the number one hospital in Texas. FORTUNE magazine has placed Houston Methodist on its annual list of “100 Best Companies To Work For” since 2006.  Houston Methodist Hospital directs millions of research dollars into patient care and offers the latest innovations in medical, surgical and diagnostic techniques. With 1,119 licensed beds, 67 operating rooms and over 6,000 employees, Houston Methodist offers complete care for patients from around the world.

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