Quality Nurse:
Baylor College of Medicine

Baylor College of Medicine
Houston Texa
Job Purpose


Reports to the Vice President, Nursing. Under general direction, designs, conducts and coordinates quality assurance and improvement activities, works collaboratively with medical staff, departments and clinics to establish and manage an effective quality assurance program for the measurement and evaluation of clinical, functional status and satisfaction outcomes, and improvement of services/outcomes throughout physician practice networks. Projects and activities are designed to improve compliance with accrediting agencies and regulatory bodies.

Job Responsibilities
  • Develops and assists with the implementation of policies and procedures for the quality to assure improved compliance with accrediting agencies and regulatory bodies.
  • Educates staff on regulation changes, and conducts orientation and regular training sessions for clinical and support staff on changes to practices and procedures. Ensures staff adherence to compliance policies and procedures specific to their jobs.
  • Coordinate and oversee Quality Improvement Plan development, review, revision, and implementation. Coordinate and integrate QI plans and processes for individual services. Coordinate the process of monitoring, measuring, and assessment of patient care and support of systems to achieve high quality, safe, cost effective healthcare services.
  • Reviews and evaluates patients' medical records, applying quality assurance criteria. Screens patient care cases and makes recommendations for physician peer review.
  • Conducts incident investigations, including root cause, “near miss” and sentinel event analysis.
  • Uses evaluation data in collaboration with other health disciplines to influence the revision of the total patient care plan or program/processes. Identifies common recurrent patient problems, symptoms and behavioral changes in relation to standards of care and patient needs, and makes recommendations for administrative change.
  • Coordinate and reports Medical Staff Quality Assurance/Improvement activities and collaborate with clinics on their Quality Metrics to develop processes for improvement to help clinics meet their target measures.
  • Quality and Patient Safety Rounding in all clinical settings, including clinical evaluation, assessment, recommendations & continuous follow up of (including but not limited to) infection prevention- sterilization & disinfection.                                                                                           
  • Develops and maintains good relations with staff and physicians.
  • Evaluates and revises program goals, policies, procedures, standards and objectives as necessary.
  • Utilizes the results of audit/quality improvement and/or research activities to improve.
  • patient care and as learning experiences for staff.
  • Designs, develops and consults on forms used for the medical record, ensuring compliance with all accrediting agencies and regulatory bodies.
  • Selects specific topics for Quality Improvement, such as problem procedures, drugs, high volume cases, high-risk cases, or other factors.
  • Works to ensure that quality improvement and innovation work remains focused on one or more of the following goals: patient-centeredness, process efficiency and waste reduction, and safe and reliable patient care.
  • Keeps abreast of all pertinent federal, state, and BCM regulations, laws, and policies as they presently exist and as they change or are modified.
Minimum Qualifications
  • Required: Associate's Degree or Bachelor's Degree in Nursing.
  • Required: Five years of relevant experience as a licensed Registered Nurse (RN), with a minimum of three years of experience in process improvement. Degrees in lieu of experience will not be accepted.
  • Required: Current license as a Registered Nurse (RN) by the State of Texas Board of Nurse Examiners.
  • Required: Basic Life Support Certification (BLS).

The position is a traveling position with most of the time servicing the Spring/ Tomball/ Woodlands/Kingwood areas and some travel to the Medical Center.





Baylor College of Medicine is an Equal Opportunity/Affirmative Action/Equal Access Employer.



Basic Qualifications