The University of Texas Medical Branch Quality Program Manager - TDCJ Hospital Administration in Galveston, Texas

Min Qualifications

Bachelor’s degree in a clinical field, health management or health related field and five (5) years of progressive responsibility, which includes clinical and quality management experience/process improvement/accreditation or comparable experience.

Job Description:

The Quality Program Manager (QPM) supports all Quality, Risk Management, Accreditation and Performance Improvement activities to include all federal, state and local regulatory compliance, and alignment with Main Campus UTMB. The QPM serves as an integral member of the UTMB Quality Department and Healthcare Safety Program, working as a partner with senior leadership in developing, executing and monitoring excellence in the delivery of patient care.

Specific Job Related Duties

  • Works collaboratively with hospital leadership and hospital Performance Improvement (PI) committee to develop plans to address annual patient safety and PI priorities and align it with UTMB quality and safety plans/priorities.
  • Facilitates/participates in and may lead collaborative interdepartmental approaches to develop and/ enhance an integrated system of care, including data management and methods and tools (e.g. PDSA, lean, causal reviews, FMEA, etc.)
  • Works with the HG Associate Medical Director to establish, implement, and monitor service level agreements and department performance standards and the appropriate use of organizational resources.


  • Oversees and supervises all quality, clinical risk, and accreditation, and patient safety, activities.
  • Responsible for centralized HG Performance Improvement activities; facilitates PI teams and supports department leaders in the conduct of local improvements.
  • Responsible for reporting Core Measures and value based purchasing activities according to TJC and CMS timelines and guidelines.
  • Performs patient chart reviews using specific indicators according to NQF and AHRQ criteria/specifications.
  • Completes chart/causal reviews on all HAC’s, PSI’s and low to moderate Risk of Mortality (ROM)


  • Reviews PSN reported events; performs initial investigation to include other referral sources. Reviews cases with UTMB main campus Risk Manager for potential presentation to the SEAT Committee on a weekly basis. Monitors timely resolution of requested SEAT action items
  • Work with campus personnel to integrate event reporting and event management, dissemination and recording of medical device recalls and alerts and management of potentially adverse events (PAE’s) and potentially compensable events


  • Works with the Assistant Medical Director to manage the continual assessment and readiness for Joint Commission accreditation for their assigned campus.
  • Coordinates educational efforts related to Joint Commission including National Patient
  • Works with leadership, physicians and HG Associate Director Ensure a coordinated response to unannounced external accrediting or regulatory agency visit by managing the process and staff.
  • Maintains familiarity with all applicable accreditation standards, keeps abreast of changes, communicates changes to leadership and chapter experts

Preferred Education


  • Master's Degree in related field.

  • Five (5) years of experience which includes two years of experience in quality management and process improvement or comparable experience.

  • Three years of progressive leadership experience.

  • Project management experience.

  • Lean Six Sigma Green Belt

Preferred License/Certificate


  • CPHQ Certification.

Equal Employment Opportunity

UTMB Health strives to provide equal opportunity employment without regard to race, color, national origin, sex, age, religion, disability, sexual orientation, gender identity or expression, genetic information or veteran status. As a VEVRAA Federal Contractor, UTMB Health takes affirmative action to hire and advance women, minorities, protected veterans and individuals with disabilities.

Full/Part Time: Full-Time

Regular/Temporary: Regular

Job Title: Quality Program Manager - TDCJ Hospital Administration

Job ID: 56262

Location: Galveston

Business Unit: TDCJH