RN Quality Management

2019-R0217369 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.


Manages the medical staff quality performance improvement program; Assesses the clinical systems, processes and outcomes related to treatment provided by the medical staff and Assists in planning performance improvement activities; Provides documentation of individual practitioners and organizational performance in accordance with standards and regulatory agencies. The position is a resource for addressing quality concerns related to the organization, patient, payers and community.


Education and Licensure Required:
Bachelor's Degree
Registered Nurse (RN)

Minimum Experience:
Five (5) years of clinical nursing experience

Minimum Knowledge, Skills, and Abilities:
Excellent communication and presentation skills are essential


1. Applies theoretical and clinical knowledge to planning quality improvement programs for the medical staff. Ensures compliance with medical staff bylaws and institutional policy within the peer review process
2. Manages the implementation of medical staff peer review programs that improve individual medical staff performance as well as system, process, and outcome performance
3. Assists the medical staff in studying physician performance by performing case review, aggregate data analysis, reporting to the medical staff sections and services, and reporting to the Quality of Care and Patient Safety Committee and Medical Executive Committee
4. Maintains accurate and complete documentation of medical staff peer review, performance improvement, and medical staff reappointment activities
5. Educates and Supports the medical staff in methods of improving CHI St. Luke's Health performance and quality initiatives
6. Collaborates with individual physicians, physician leadership, hospital administration including risk management and legal services, and other healthcare professionals as needed
7. Manages assigned service lines and peer review activities to facilitate total quality improvement processes for practitioners and for the hospital
8. Manages information to ensure compliance with mandates of various regulatory agencies
9. Utilizing principles of shared governance, the MSQM is responsible writing policy and procedures, creating job descriptions and evaluation forms, and hiring and training of new employees for the department. The MSQM will participate in the Quality of Care and Patient Safety Committee and service meetings
10. Partners with Information Technology to ensure integrity of data, and as needed for the department

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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