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Memorial Hermann Health System

Quality Manager - Hospital

Houston, Texas


As part of our commitment to deliver extraordinary patient care, we redesigned our care management function. On this integrated care team, you’ll be empowered to streamline practices, improve safety and reliability of care, develop standards for medical necessity, reduce costs by eliminating unnecessary variation, and ultimately, create a better patient experience. You’ll help ensure every patient who walks through our doors receives an exceptional end-to-end patient care experience and gets home quickly and safely.

  • Job Type: Full-Time, Part-Time, PRN
  • Job Level: Mid
  • Travel: No
  • Glassdoor Reviews and Company Rating Glassdoor Reviews and Company Rating


What makes someone successful at Memorial Hermann?
Check out the top traits we're looking for and see if you have the right mix.

  • Collaborative
  • Detail-oriented
  • Efficient
  • Independent
  • Multi-tasker
  • Organized


As a part of the Care Management team, we get to help navigate and support patients, families, and the medical care team through complicated situations.

– Michelle O., Case Manager


  • Health Insurance

  • Retirement Plan

  • Paid time off

  • Certification reimbursement

  • Tuition reimbursement

  • Student Loan Repayment


Title Quality Manager - Hospital Location 7600 Beechnut Street, Houston, TX 77074 Category Quality & Patient Safety Type Full time Requisition 100114139 Date posted 09/09/2021

At Memorial Hermann, we’re about creating exceptional experiences for both our patients and our employees. Our goal is to provide opportunities for our diverse employee population that develop and grow careers in a team-oriented environment focused on patient care.

Every employee, at every level, begins their journey at Memorial Hermann learning about the history of the organization and its established culture built on trust and integrity. Our employees drive this culture, and we want you to be a part of it.

Job Summary

The Performance Improvement Specialist is responsible for driving progress of robust process improvement projects at the local level. The PI Specialist will facilitate and coordinate quality, process, and performance improvement activities using robust process improvement methodology and maximize identification of process defects and replication of proven improvement strategies. The components of robust process improvement program include, but are not limited to appropriate prioritization of projects based on strategic goals, level of urgency and availability of robust data. The PI Specialist works collaboratively with local key stakeholders including process owners, organization leaders and physicians. The Performance Improvement Specialist is responsible for review and analysis of Quality, Patient Safety, and Infection Prevention data to identify opportunities for improvement; identifies subject matter experts and core teams, facilitates implementation plans, finalizes control or monitoring plans, shares best practices to allow for local as well as system-wide learning, collaborates with hospital Councils to share knowledge leading to optimal outcomes and continuous education of robust process improvement within the hospital. The PI Specialist also participates in the clinical quality measures data collection and acts as a resource for accomplishing inter-rater reliability in clinical quality data collection and submission.

Job Description

Minimum Qualifications:

Bachelor’s Degree in Nursing (BSN) preferred, must be obtained within 2 years.

Robust Performance Improvement Certification required or within twelve months of employment. (Project Management Professional or Six Sigma Green Belt).

Minimum one year experience in robust process improvement.

Minimum three years acute hospital-based experience.

Knowledge of leading practice in clinical care and regulatory and accreditation requirements.

Knowledge of quality measures up to date specifications (e.g. Core Measure Specifications for TJC/CMS ).

Self-motivated, proven communication skills, assertive.

Demonstrated effective working relationship with physicians and leadership.

Ability to work collaboratively with health care professionals at all levels to achieve established goals and improve quality outcomes.

Strong team facilitation skills including building trust and open communication regarding project issues and results.

Statistical software proficiency preferred (i.e. Engine Room, Minitab, JMP).

Demonstrates commitment to the Partners-in-Caring process by integrating our culture in all internal and external customer interactions; delivers on our brand promise of “we advance health” through innovation, accountability, empowerment, collaboration, compassion and results while ensuring one Memorial Hermann.

Principle Accountabilities:

Participate in and coordinate comprehensive data collection for compliance of national, state, regional and internal clinical quality measures including concurrent core measures review and/or centralized abstraction.

Assists in identifying local clinical quality measures improvement opportunities based on evidence based clinical practices and statistical analysis of current practice patterns.

Contributes to local clinical quality measures data collection, aggregation, and dissemination.

Contributes to short term and long term local clinical quality measures robust process improvement projects to continuously improve the clinical quality measuring, monitoring and compliance program.

Develops and implements a plan for essential data collection, thorough analysis and effective data manipulation at the local level.

Works with robust process improvement sponsor for improvement strategies.

Educates local staff and physicians to provide evidenced based care and improve clinical outcomes.

Educates and mentor hospital staff on robust process improvement techniques.

Participates in validating accurate clinical quality measures abstraction through systematic inter rater reliability processes.

Facilitates site or hospital robust process improvement project teams.

Shares best practices to allow for hospital as well as system-wide learning.

Collaborates with enterprise quality and patient safety program, in particular the centralized abstraction function, to share knowledge leading to better outcomes.

Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.

Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.

Other duties as assigned.

Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the patient served.  Must demonstrate knowledge of the principles of growth and development as it relates to the different life cycles.  Specific age groups that are served by this position are circled:

|      Neonate      |         Infant         |      Pediatric      |    Adolescent    |         Adult         | Adult/Geriatric |

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