Clinical Quality Specialist

Professional Non-Clinical
2019-R0228115 Requisition #
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Baylor St. Luke’s Medical Center

A quaternary care facility that is home of the Texas Heart® Institute, a world-class cardiovascular research and education institution founded in 1962 by Denton A. Cooley, MD–consistently ranked as one of the nation’s best in Cardiovascular Services & Heart Surgery.
The first hospital in Texas and the Southwest designated a Magnet® hospital for Nursing Excellence by the American Nurses Credentialing Center, receiving the award four consecutive times. Baylor St. Luke’s is home to three freestanding community emergency centers (Holcombe, Pearland, and San Felipe) offering adult and pediatric care–treating more than 51,000 patients annually. The hospital holds a collaborative partnership with Baylor College of Medicine and affiliations with The University of Texas Medical School at Houston, The University of Texas Medical Branch (Galveston), Houston Baptist University, and Prairie View A&M University.


Responsible for reviewing reports, investigating and analyzing critical events, managing data and updating central databases, assisting with root cause analysis, determining appropriate patient/provider and reporting follow-up and needed support, identifying opportunities to improve future patient care, and preparing and presenting reports for department meetings. Assists with quality/process improvement efforts, and collaborates with physicians and staff on patient safety initiatives. Maintains communications with Administration, Medical Staff and Department Heads regarding the Quality Assurance activities.


Education and Licensure Required:
*Bachelor's Degree

Minimum Experience:
*Three (3) years of related work experience in critical care or comparable high acuity patient care setting


1. Serves as a clinical resource for continuous compliance with the rules, regulations, and laws of local, state, and federal regulatory agencies.
2. Collaborates with management in monitoring and evaluating quality of care and patient outcomes based upon standards of care as well as the findings of nursing research, hospital policies/procedures, and applicable patient care protocols.
3. Identifies opportunities for improvement, and facilitates the development of action plans in collaboration with staff and management.
4. Supports management and staff in utilizing Performance Improvement tools.
5. Plays a leadership role in Quality Assurance activities, utilizing a multidisciplinary model. Makes recommendations for change in practice to improve patient outcomes.
6. Attends monthly unit and hospital Quality Assurance meetings and reports information back to department in a timely manner.
7. Serves as a clinical resource when opportunities for improvement or correcting deficiencies are noted, and Develops action plan as appropriate.
8. Collaborates with management in designing activities to assist the staff in acquiring, maintaining, or increasing competence in his/her role responsibilities, including designated mandatory in-service requirements for all staff.
9. Participates in the development, implementation, and evaluation of education/orientation programs for staff and patients.
10. Participates in the development, implementation, evaluation and revision of order sets, policies, and other documentation.
11. Monitors documentation on patient record based on standards and policies.
12. Monitors outcomes of process/system changes, and reports variances to appropriate management and staff.
13. Maintains knowledge of current trends health care delivery
14. Leads Policy & Procedure management process.
15. Performs chart audits, Provides analysis & recommends change as necessary.

About Us

Chances are, you’re here because you’re looking for a career offering greater opportunity, challenge and fulfillment. We’re confident you’ll find all three at CHI. As one of the nation’s largest nonprofit health systems, we offer a wealth of careers across more than 101 hospitals in 18 states. Our faith-based health system welcomes you to share in our mission of building healthier communities, whether as a surgeon in the operating room or an administrator in a conference room. When you work in a supportive environment with like-minded professionals, wonderful things happen. Learn More

Equal Opportunity Employment

Consistent with our Core Values, Catholic Health Initiatives employers are EEO/AA/M/F/Vets/Disabled Employers. Qualified applications will receive consideration for employment without regard to their race, color, religion, national origin, sex, sexual orientation, gender identification, protected veteran status, disability or any other legally protected characteristic

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