Registered Nurse Quality Coordinator

JOB SUMMARY: The Risk Management Nurse has primary responsibility for supporting the hospitals clinical risk management and patient safety programs. This role involves the daily review of patient safety event reports, timely escalation of high-risk events, and comprehensive follow-up. The Risk Management Nurse assists with Failure Mode and Effects Analysis (RMEA), Root Cause Analysis (RCA), and other risk related investigations and activities, and provides education to hospital staff and physicians on culture of Safety and Patient Safety Reporting. Additionally, this nurse develops and tracks corrective action plans, reports findings to relevant hospital committees, and works directly with the Quality Analyst to manage legal cases, patient complaints and grievances, regulatory surveys (including tracking and closing survey findings and related documentation), and compliance and regulatory issues. This role does not perform medical staff peer review activities.

Shift: Monday- Friday

DUTIES AND RESPONSIBILITIES:

SERVICE:

Consistently supports the hospital's Mission, Vision and Values of St. Joseph Medical Center (SJMC).

Follows the SJMC Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).

Promotes a Culture of Safety for patients, staff, and physicians by providing ongoing education and training on patient safety principles, risk reduction, and timely, accurate Patient Safety Reporting.

PEOPLE:

Collaborates with the Quality Analyst to manage, investigate, track, and resolve patient and family Complaints and Grievances in accordance with CMS Conditions of Participation and hospital policy.

Partners with the Quality Analyst on regulatory readiness, including tracking, managing documentation for, and closing out corrective actions related to accreditation and regulatory surveys (e.g., CMS, State, DNV/The Joint Commission).

Assists in the Quality Analyst and hospital leadership in addressing ongoing clinical compliance and regulatory issues across hospital departments.

QUALITY:

Conducts daily review and triage of all hospital event/incident reports, ensuring appropriate investigation, timely escalation of serious or potentially compensableevents to leadership, and thorough follow-up through resolution.

Assists with facilitating and conducting Root Cause Analyses (RCA), Failure Mode and Effects Analyses (FMEA), and other proactive and reactive clinical risk management assessments.

Collaborates with department leaders and clinical teams to develop, implement, and monitor measurable Corrective Action Plans (CAPs) resulting from event investigations, RCAs, FMEAs, and regulatory findings.

Prepares and presents risk management summaries, trend analyses, corrective action updates, and safety reports at relevant hospital and quality/safety committees. (Note: Does not perform medical staff peer review activities.)

Works directly with the Quality Analyst to manage and coordinate medical-legal cases, including chart preservation, clinical timeline preparation, discovery support, and liaison activities with legal counsel and risk claims management.

GROWTH:

Fosters a positive relationship with internal and external customers and utilizes growth opportunities in the department as well as within the risk management field.

Support hospital initiatives by contributing to safety surveys and safety initiatives within the organization and within the industry by focusing on preventive solutions to reduce harm.

Demonstrates the ability to address issues and activities that encompass the larger aspect of hospital operations, communicating effectively with associates at all levels, physicians, leadership, and external stakeholders to meet established safety and risk goals.

Maintains knowledge of risk management and event reporting database applications, analyzing statistical data to identify clinical risk trends, adverse event patterns, and opportunities for system-wide safety improvements.

Sets an example for all staff in their daily activities.

MINIMUM KNOWLEDGE, SKILLS AND ABILITIES REQUIRED:

Work Experience: Work requires a professional knowledge of clinical risk management, patient safety methodologies (RCA, FMEA), regulatory and accreditation compliance, complaint/grievance management, patient care practices, event reporting database literacy, and statistical/trend analysis techniques.

License/Registration/Certification:

Licensed as a Registered Nurse in the State of Texas (ADN).

CPHRM (Certified Professional in Healthcare Risk Management).

CPPS (Certified Professional in Patient Safety.

Able to effectively communicate in oral and written English language.

Able to effectively navigate the electronic health record.

Skills:

Conduct daily clinical event reviews, triage risk severity, and escalate critical safety issues appropriately.

Facilitate Root Cause Analyses (RCA), Failure Mode and Effects Analyses (FMEA), and Corrective Action Plan (CAP) development and tracking.

Educate and engage nursing staff, ancillary staff, and physicians on Culture of Safety and Patient Safety Reporting.

Plan, schedule, and develop task/timelines for corrective actions and survey closuredocumentation.

Read, interpret, and apply clinical information, legal/risk documentation, and complex regulatory standards.

Lead work groups, communicate orally in small and large groups, and prepare clear committee reports in written formats.

Manage and define processes and projects to achieve identified risk reduction and compliance goals within specified timelines.

Manage confidential risk, legal, complaint/grievance, and survey records and file documentation (both hard copy and electronic).

Strong analytical and problem-solving abilities for system-based risk identification.

Understand hospital and health system organizations and operations.

Work autonomously and collaboratively with the Quality Analyst, hospital leadership, and multidisciplinary clinical teams.

Maintain the interests of the hospital while fostering confidence, respect, and trust with staff and physicians in a just safety culture.

Ability to integrate and interpret data from diverse sources addressing issues of high complexity.

Ability to develop strong working relationships with internal and external stakeholders (i.e., physicians, leaders, associates, legal/regulatory representatives).

PREFERRED:

Bi or Multilingual

Licensed as a Registered Nurse in State of Texas, BSN preferred

CPHQ, preferred

Houston's oldest hospital is GROWING!

Welcome to St. Joseph Medical Center (SJMC), Houston's first and only downtown hospital delivering world-class care for the last 137 years and looking forward to the next century of exceptional care to Houstonians when they need us most.

Whether it's for a scheduled surgery, the birth of a baby, an unexpected emergency, or an outpatient visit, we have staff available around the clock to provide you access to immediate, quality health care. SJMC has been providing health care services to Greater Houston residents for over 130 years, which should give you great comfort in knowing that we have a great tradition of caring for our community. We strive to meet our patients' expectations and encourage our patients to provide us with feedback on how we can help them have the best experience possible while they're in our care.

Over the last years we have expanded our services to include the Advanced Wound Care Center, Comprehensive Cardiac and Vascular Services, the Women's Center, the St. Joseph Maternal Fetal Medicine Center, and a Weight Loss Surgery Program, just to name a few. As you work with our physicians, nurses, case managers, educators, and other staff, you will be guided through your health care journey, from diagnosis to treatment, with compassion every step of the way.

Diversity, equity, inclusion, and belonging are at the foundation of the care St Joseph Medical Center provides to our community we are privileged to support in all of our employment practices. We do not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity, or expression or any other non-job-related characteristic.