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Director Quality - Patient Safety
Company : Catholic Health Initiatives
Location : Sugar Land, TX, 77478
Job Type : Full Time
Salary : 51.03-75.9 HOUR
Date Posted : 3 January 2026
Job Summary and Responsibilities
This position is responsible for the design, coordination, implementation and management of the Organization's Performance Improvement (PI) and Patient Safety plans and identifies opportunities for improved patient care and outcomes and reductions in harm, with the implementation of evidence-based practices. Provides leadership in defining, implementing and integrating quality, safety, service and efficiency strategies into the plans, policies, and organizational processes that affect the organization's operations and strategic direction.
Establishes performance improvement goals annually with relevant stakeholders. Ensures the Performance Improvement Plan and the hospital-focused projects for the year are implemented and their effectiveness is evaluated annually. Develops and implements processes and formats which support data collection, aggregation, analysis, and action planning. Assures data is managed appropriately and disseminated to appropriate leadership staff. Provides leadership in developing quality improvement and patient safety training programs and coaches organizational clinical/service lines and operational/support departments in quality improvement principles. Implements and oversees the organization-wide patient safety program and manages the reporting, data analysis and evaluation as outlined in the Patient Safety Plan. Oversees the events reporting process, root cause analyses, investigations and requests from the claims team (including management of subpoenas, Summons and Complaints, and coordination of legal documents related to hospital liability). Participates in system office initiatives and programs to mitigate risks in the facility which have been identified at other hospitals, resulting in reduced costs, adverse patient outcomes and ultimately safer patient practices and care. Collaborates with the Medical Staff and Organizational Leadership to develop and enhance safe patient care while achieving optimal outcomes, including the organization’s peer review program and ongoing and focused practitioner evaluation.
Provides leadership and is responsible for accreditation and regulatory survey readiness. Oversees mock survey tracers to assess survey readiness. Provides education to staff and providers on regulatory compliance. Organizes required staff to develop responses to survey deficiencies and submits responses to the appropriate accreditation or regulatory agency. Has overall accountability for assigned work group relative to operational goals, personnel requirements, and budgetary constraints.
Job Requirements
Required Education and Experience:
Bachelor's degree in healthcare or five (5) years of related job or industry experience in lieu of a degree.
Minimum of five (5) years of progressive management responsibility in a health care setting
Two (2) of which is related to managing an acute care organization’s Quality Improvement Program.
Minimum of two (2) years of clinical, patient care experience or equivalent.
Experience developing and implementing clinical, service and operational process improvement initiatives, both small and large scale.
Experience with the event reporting process, root cause analyses, and event investigation/review.
Experience with patient compliant/griev ance investigations and prompt resolution.
Five (5) years’ experience in Quality Management can be used in lieu of state license.
Required License and Certifications:
State License in a clinical field
Certification required in one of the following (or within 24 months of hire):
Certified Professional in Healthcare Quality (CPHQ)
Healthcare Quality Mgmt (HCQM)
Cert Prof Healthcare Qual (CPQPS)
Where You'll WorkSt. Luke's Health–Sugar Land Hospital offers the latest technology and treatments for residents of Fort Bend County and Southwest Houston. Our services range from heart care and neuroscience to robotic surgery. Our recently opened Family Birthing Center offers incomparable care and amenities in a spa-like environment to provide a VIP—Very Important Pregnancy—experience. Since 2008, our experienced doctors, nurses, and support staff have provided expert care to support our community.
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Frequently asked questions
Strong strategic thinking, effective communication with clinical teams, and expertise in performance improvement methodologies are vital. A director in patient safety must inspire collaboration across departments to drive quality initiatives and ensure adherence to safety protocols, fostering a culture of continuous improvement.
This position integrates safety and quality strategies directly into hospital workflows, ensuring that patient care standards meet regulatory requirements. By managing risk mitigation and monitoring clinical outcomes, the director helps maintain smooth operations and supports staff in delivering safer, efficient care in the Sugar Land healthcare environment.
Certifications like Certified Professional in Healthcare Quality (CPHQ) or Healthcare Quality Management (HCQM) are highly regarded. In Texas, these credentials demonstrate commitment to clinical quality standards and patient safety excellence, often boosting eligibility for leadership roles within hospitals like St. Luke’s Health in Sugar Land.
Catholic Health Initiatives emphasizes integrating evidence-based practices with community-focused care. Their directors lead comprehensive quality programs that not only address regulatory compliance but also foster innovation in patient safety, encouraging proactive risk management tailored to local population health needs.
St. Luke’s leverages cutting-edge technology and multidisciplinary teams to back quality initiatives. The director benefits from robust data analytics tools and collaborative clinical staff, enabling effective root cause analyses and targeted interventions that enhance patient safety and improve care delivery.
Directors in this role typically earn between $120,000 and $150,000 annually in Sugar Land, reflecting regional cost of living and healthcare market demand. This range aligns closely with Houston metro area standards, balancing experience and leadership responsibilities in quality management.
A frequent misunderstanding is that this role only involves compliance or paperwork. In reality, it demands proactive leadership in clinical risk reduction, continuous data-driven improvements, and staff education, all crucial for transforming patient care culture and minimizing harm.
The Sugar Land healthcare sector is growing, but quality leadership roles remain specialized with moderate competition. Candidates with strong clinical backgrounds and certifications have an advantage, as local hospitals prioritize experienced professionals capable of driving measurable improvements.
They might lead root cause analyses after adverse events, coordinate with legal and clinical teams during investigations, and develop corrective action plans. Balancing transparency with regulatory compliance ensures patient trust while mitigating future risks within the organization.
Yes, directors must navigate Texas-specific healthcare laws alongside national standards from agencies like The Joint Commission. Staying current with both state regulations and accreditation criteria is essential to maintain hospital readiness and uphold patient safety benchmarks.