Quality Improvement Leader

Under limited supervision plans coordinates leads and monitors quality improvement initiatives within clinical service departments and across the UMMC Downtown campus (organization).  Communicates with organization leadership (Directors Chairs VPs SVPs) clinical teams and other departments (Performance Innovation Infection Prevention Nursing etc.) to drive organizational change toward high reliability and Zero Harm. Ensures awareness of and continuously implements the UMMC Quality Assurance/Performance Improvement (QAPI) program and the Annual Operating Plan (AOP) goals. Provides leadership and direction to multidisciplinary teams (which include physicians and senior leaders) to collaboratively accomplish quality improvement strategies at UMMC. Accountable for overall quality of care provided to all patients in the designated clinical service departments as well as compliance with quality requirements as outlined by CMS Joint Commission and/or disease specific certifications.  Collects and analyzes data conducts presentations provides consultation and staffs and leads service specific and organizationwide committees. Promotes UMMC on its journey to become a High Reliability Organization (HRO) through the use of robust quality improvement tools and by promoting a Just Culture.

The position encompasses various roles (ex. subject matter expert coordinator educator project manager data analyst and facilitator) and requires effective interpersonal management and leadership skills. A working knowledge of clinical workflows and strong leadership skills are therefore integral to gaining credibility and collaboration from colleagues. Duties include working with UMMC clinical service departments on quality improvement strategies to 1) enhance clinical/patient outcomes 2) maximize the organizations financial reward within the State of Marylands pay for performance programs and 3) optimize the organizations ranking within Vizients Quality and Accountability (Q&A) dashboard. This role works with organization leadership staff advanced practitioners and physicians to provide a planned systematic organizationwide approach to identify measure monitor and evaluate quality improvement activities to foster a Zero Harm environment while promoting principles of a High Reliability Organization. This position develops and maintains interactive and collaborative relationships with key medical staff (including Chairs); collaborates with and provides structure and guidance to clinical service departments; and serves as a vital quality improvement resource to clinical teams and support staff including faculty unit dyads and frontline team members.

1. 1. Assists in the coordination and implementation of activities in the journey to become a high reliability organization with a focus on Zero Harm
   2. Collaborates with organization and Quality leadership to direct and implement the bicampus integrated quality improvement program including:
      1. Quality Program Management
         1. Oversees implementation of the quality improvement program for improving organizational performance. This includes planning organizing leading and directing clinical service department and organizationwide quality improvement activities by facilitating and leading multidisciplinary teams which include physicians and senior leaders. 
         2. Develops and leads projects of identified problem areas in accordance with organizational department and clinical service strategic priorities including UMMCs QAPI program AOP goals the State of Marylands pay for performance programs and the Vizient Q&A dashboard. Occasionally these projects may cross both campuses.
         3. Actively collects reviews analyzes and monitors organizational performance data to identify trends that may impact patient care and/or the organizations financial performance. Independently and in collaboration with organizational leadership and clinical service departmental leadership identifies and prioritizes opportunities for quality improvement projects evidencebased practice changes and improved efficiencies based on the organizations performance and strategic priorities.
         4. Leads and manages special quality improvement projects by identifying resources needed persons to be involved and project management requirements necessary to complete the project. Occasionally these projects may cross both campuses.
         5. Collaborates with organizational and departmental leadership to prioritize improvement efforts.
         6. In order to sustain improvements responsible for ensuring action plans are implemented before handingoff to service line leaders for continued monitoring.
         7. Active participation (including membership or chair/cochair role) in key organizational quality improvement committees teams and projects including but not limited to: quality steering committees diagnosisspecific committees (sepsis heart failure etc.) and/or clinical service departmentspecific committees (critical care cardiac surgery etc.). At times these committees/teams/projects may cross both campuses.
      2. Leadership
         1. Works collaboratively with staff senior leaders clinical service department Chairs and Lead Quality Physicians to identify and establish quality improvement priorities that align with UMMCs strategic initiatives including but not limited to the QAPI program and the AOP goals.
         2. Partners with UMMC leadership to prioritize facilitate and advance the ongoing focus on a culture of quality improvement and Zero Harm
         3. Facilitates clinical review and problemsolving processes through the use of quality improvement methodology and tools including by not limited to: Root Cause Analysis (RCA) Plan Do Check Act (PDSA) Process Improvement methodology and Lean methods.
2. 1. 1. 1. Meets regularly with Lead Quality Physician in order to determine departmental and organizational quality focus and priorities; to review data to be presented at departmental quality improvement meetings; and to identify and present quality issues that need to be addressed.
         2. Develops and implements education for employees and medical staff to foster understanding of quality improvement methodologies and goals including contributing to the bimonthly Quality Matters Newsletter.
         3. Provides justintime training on process and quality improvement tools and techniques to support executive champions leaders and quality improvement teams.
         4. Keeps quality improvement teams on track with timelines and expected results based on the project charter.
      2. Data Management
         1. Supports improvement work for the following metrics within the State of Marylands payforperformance programs and/or the Vizient Q&A dashboard:
            1. Potentially Preventable Complications (PPCs)/Patient Safety Indictors (PSIs)
            2. Mortality
            3. Timely followup (TFU)
            4. Other metrics within the HSCRCs Quality Based Reimbursement program as deemed appropriate by Quality and organizational leadership and/or
            5. Other metrics that may impact the financial performance of the organization.
         2. Monitors quality indicators to identify trends and areas for improvement that are aligned with the organizations strategic objectives.
         3. Maintains and ensures accuracy of departmental and organizationwide dashboards (ex. the QSDR and the Quality Dashboard by Service) in collaboration with the Office of Healthcare Analytics and Informatics (OHAI).
         4. Independently and in collaboration with stakeholders identifies trends or patterns that present an opportunity to improve the quality and safety of patient care. Occasionally these trends or patterns may cross both campuses.
         5. Provides consultation to ancillary support and clinical departments within UMMC to establish quality indicators analyze quality and utilization data identify trends/patterns and formulate plans for resolving issues/problems.
   2. Provide leadership in the development and implementation of departmental and organizational strategies regarding regulatory compliance including:
      1. Ensures compliance with regulatory standards within the Joint Commission Performance Improvement (PI) Chapter and the CMS Condition of Participation (42 CFR 482.21) related to the organizations QAPI program.
      2. May participate and assist with organizational visits from accrediting agencies (TJC CMS etc.).
      3. May participate in organizationwide Joint Commission tracers providing realtime staff education related to regulatory quality compliance and hospital policy requirements.
      4. May oversee actions taken in response to recommendations for improvement around quality deficiencies identified by regulatory agencies.

Qualifications :

Education and Experience

• 1. Bachelors degree in Nursing or a related health science field. Masters Degree preferred.
  2. Current licensure in Nursing or related field is required (i.e. nursing physical therapy).
  3. Three years of progressively responsible professional experience performing quality improvement activities or equivalent is required.

Knowledge Skills and Abilities

• 1. Demonstrated broad based knowledge of quality improvement methodology analysis and improvement strategies is required.
  2. A history of demonstrated leadership success.
  3. Proficiency and demonstrated effectiveness in problemsolving analytical skills and implementation of new processes or programs.
  4. Ability to facilitate clinical quality improvement and the problemsolving process in a clinical setting. 
  5. Proficiency in monitoring evaluating and motivating the performance of clinical and nonclinical professionals and the ability to coach and lead staff.
  6. Ability to work with limited supervision in the management of projects and programs is required. Initiative and problemsolving skills are needed.
  7. Ability to develop collaborative programs and projects with other disciplines (clinical and nonclinical) is required. Must be able to contribute to team effectiveness build relationships and facilitate improvements.
  8. Knowledge of state and federal regulations and The Joint Commission standards and practices for acute care hospitals is required.  Knowledge of Departmental of Health and Mental Hygiene (DHMH) for state licensure and medical conditions of participation. Familiarity with physician practice standards and legal and ethical practices
  9. Highly effective verbal and written communication skills are necessary to work with all levels of personnel administrators and clinical staff in monitoring and evaluating the quality of patient care.
  10. Ability to assess safety quality and regulatory compliance problems recommend solutions and assist responsible areas to resolve issues in a timely efficient and effective manner.
  11. General knowledge of PC and database management software packages is required.
  12. Basic project management skills
  13. Strong presentation skills including executive level presentations.

Additional Information :

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 Compensation

• Pay Range: $40.61$60.96
• Other Compensation (if applicable):

Review theUMMS Benefits Guide