At Houston Methodist, the Manager Quality position is responsible for providing direct supervision of performance improvement staff and oversight of quality initiatives in collaboration with medical staff, hospital staff, and leadership. This position serves as mentor, coach, or direct management of interdisciplinary processes to facilitate improvement efforts relevant to clinical care. The Manager Quality position facilitates and directs implementation of evidence-based practice using data and performance improvement methodologies and oversees the review, analysis, and integration of data in workflow design to support organizational mission and goals. This position facilitates data analysis and reporting to improve clinical outcomes.

The manager position responsibilities include managing the daily work activities of the work unit/department staff, ensuring quality, productivity, functional excellence and efficiency while assisting management in accomplishing strategic and operational objectives. In addition, this position provides guidance to staff and is responsible for staffing, budget compliance, contributing to staffing decisions such as hiring and terminating employment, coaching and counseling employees on work related performance, and assisting in the development and implementation of policies and procedures to ensure a safe and effective work environment. This position also implements training, monitoring and operations initiatives that assure compliance with ethical and legal business practices and accreditation/regulatory/ government regulations.

PATIENT AGE GROUP(S) AND POPULATION(S) SERVED
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.

HOUSTON METHODIST EXPERIENCE EXPECTATIONS

• 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.

• Practices the Caring and Serving Model

• Delivers personalized service using HM Service Standards

• Provides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET, Managing Up, Key Words)

• Intentionally collaborates with other healthcare professionals involved in patients/customers or employees' experiential journeys to ensure strong communication, ease of access to information, and a seamless experience.

• Involves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given job

• Displays cultural humility, diversity, equity and inclusion principles

• Actively supports the organization's vision, fulfills the mission and abides by the I CARE values

PEOPLE ESSENTIAL FUNCTIONS

• Performs management responsibilities of selection, scheduling, supervision, retention, and evaluation of employees in the Quality department. Provides development and mentoring of staff. Meets or exceeds threshold goal for department turnover. Develops direct reports to perform these same functions.

• Provides leadership and communication to maintain a competent and engaged employee group by conducting regular department meetings to review policies and procedures and operational matters, rounding on all employees, completing performance appraisals, conducting new hire feedback sessions, coaching/corrective counseling, and providing recognition/commendations to achieve desired outcomes. Provides timely guidance and feedback to help others strengthen specific knowledge/skill areas needed to accomplish a task or solve a problem.

• Facilitates the promotion of teamwork within and between departments; participates and/or leads and facilitates department process improvements as needed.

• Meets or exceeds threshold goal for department and/or system metrics on employee engagement indicators: action readiness score, tier level.

• Supports an environment for the team to create timely action plans. Proactively and effectively develops and maintains collaborative relationships with physicians, hospital leaders and their employees. Utilizes performance improvement tools appropriately to manage desired outcomes.

SERVICE ESSENTIAL FUNCTIONS

• Plans and organizes day-to-day Quality department operations, schedule and activities. Sets priorities and functional standards, giving direction to staff as necessary to ensure the best possible delivery of service and high customer/patient satisfaction.

• Drives department service standards and activities to impact department and/or system score for patient/customer-based satisfaction, through role modeling and fostering accountability. Serves and actively participates on various entity committees as a voice for the Quality department.

• Develops high quality presentation materials that clearly outline performance improvement initiatives and lay out a logical and compelling storyline that drives toward a recommendation or set of strategic consideration.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Ensures a safe and effective working environment; monitors and/or revises the Quality department safety plan and/or any specific accreditation/regulatory required safety guidelines.

• Uses and optimizes information systems to enhance operations; supports entity-specific performance improvement and data management/analysis functions.

• Employs a proactive approach in the optimization of safe outcomes by monitoring and improving the department workflow, using peer-to-peer accountability, and identifying solutions via collaboration. Adopts lean principles in driving process improvements. Role models situational awareness, using teachable moments to improve safety.

• Monitors self and employee compliance with policies, procedures, and System HR Standards of Practice and performs associated actions upon non-compliance (i.e., focal point review requirements, disaster plan, in services, influenza immunization, wage and hour, standard hours, timely termination submission, timely timecard approval, etc.).

• Identifies quality improvement opportunities through analysis of facility and external benchmark data. Appropriately delegates and manages outcome for project assignments to qualified staff. Supports facility external benchmarking initiatives.

FINANCE ESSENTIAL FUNCTIONS

• Assists in the development of department budget and ensures that the department operates in a cost effective manner. Manages/audits department expenses within approved budget parameters, ensuring that the Quality department meets the budgeted/flex revenue and/or expense targets on a monthly and annual basis. Develops staffing plans and schedules to meet department needs that reflect understanding of the importance of cost-effectiveness.

• Implements department strategies to achieve financial target and staffing needs, developing others to do the same, through optimizing productivity, supply/resource efficiency, minimizing incidental overtime and overtime percentage, and other areas according to department specifications.

• Identifies strategies and opportunities for financial efficiency and improvement of operations.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Identifies and implements innovative solutions for practice or workflow changes to improve department operations or other department-specific measures by leading unit projects and/or other department/system directed activities. Supports change initiatives, maintaining effectiveness when experiencing major changes in work responsibilities or environment; adjusts effectively to work within new work structures, processes, requirements or cultures.

• Proactively evaluates processes; recommends and implements action plan(s) for change. Participates in the development and implementation of new procedures and the review and revision of existing procedures.

• Identifies opportunities and takes action to build strategic relationships between one's area and other areas, teams, departments, and units to achieve business goals.

• Seeks opportunities to identify developmental needs of self and staff and takes appropriate action. Ensures own career discussions occur with appropriate management. Completes and updates My Development plan on an on-going basis. Conducts conversations with staff on their development.

• Drives and participates in the process of innovation to drive teams to new avenues of growth.

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.

EDUCATION

• Master's degree in allied health, healthcare administration, business administration or a clinical discipline

WORK EXPERIENCE

• Three years of progressively responsible staff experience within hospital quality/ performance improvement/project management

• Two years of management experience preferred

• Two years of experience with decision support, clinical database development or research preferred

LICENSES AND CERTIFICATIONS - REQUIRED

• N/A

LICENSES AND CERTIFICATIONS - PREFERRED

• CPHQ - Certified Professional in Healthcare Quality (NAHQ) OR
• PMP - Certified Project Management Professional (PMI) OR
• Lean Six Sigma Certification-IASSC OR
• Specialty certification in clinical discipline

KNOWLEDGE, SKILLS, AND ABILITIES

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations

• 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 through a variety of channels with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles; engages the recipient(s) and helps them understand and retain the message

• Demonstrates the ability to interact with others in a way that gives them confidence in one's intentions and those of the organization

• Ability to use appropriate interpersonal styles and techniques to gain acceptance of ideas or plans; modifying one's own behavior to accommodate tasks, situations and individuals involved

• Demonstrates leadership qualities and critical thinking through self-direction initiative and effective interpersonal skills and oral/written communication skills

• Ability to identify and understand issues, problems and opportunities, comparing data from different sources to draw conclusions; using effective approaches for choosing a course of action or developing appropriate solutions; taking action that is consistent with available facts, constraints and probable consequences

• Ability to work effectively in a fast paced environment

• Demonstrates flexibility and adaptability in the workplace

• Demonstrates experience in understanding and executing performance improvement concepts and activities

• Ability to manage and manipulate large scale longitudinal data sets covering multiple populations

• Advanced skill in use of spreadsheet and relational database software

• Strong presentation skills and ability to facilitate work teams.

• Skill in use of clinical and operational outcomes and comparative performance benchmark databases

SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE

• Uniform No
• Scrubs No
• Business professional Yes
• Other (department approved) No

ON-CALL*
*Note that employees may be required to be on-call during emergencies (ie. DIsaster, Severe Weather Events, etc) regardless of selection below.

• On Call* No

TRAVEL**
**Travel specifications may vary by department**

• May require travel within the Houston Metropolitan area No
• May require travel outside Houston Metropolitan area No

Houston Methodist West Hospital is committed to leading medicine in West Houston, Katy and surrounding communities by delivering the Houston Methodist standard of exceptional safety, quality, personalized service and innovation. The growing campus offers more than 200 beds, 19 operating rooms and over 1,500 employees, with access to the most innovative medical and surgical care available, including robotic and minimally invasive surgery, full-spectrum heart care, state-of-the-art imaging, cancer care, labor and delivery with a level II neonatal ICU, neurology and neurosurgery, orthopedics and sports medicine, outpatient rehabilitation and 24/7 emergency services.