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Exemption Status:

Hiring Range:

Please note that the final offer may vary within this range based on a candidates experience skills qualifications and internal equity considerations.

Schedule Details:

Scheduled Hours:

Shift:

Hours:

Cost Center:

This position may have a signing bonus available a member of the Recruitment Team will confirm eligibility during the interview process.

Everyone Is a Caregiver

At UMass Memorial Health everyone is a caregiver regardless of their title or responsibilities. Exceptional patient care academic excellence and leading-edge research make UMass Memorial the premier health system of Central Massachusetts and a place where we can help you build the career you deserve. We are more than 20000 employees working together as one health system in a relentless pursuit of healing for our patients community and each other. And everyone in their own unique way plays an important part every day.

I. Major Responsibilities:
1. Leads as a change agent improvement advisor and facilitator. Manages change in a planned and productive manner.
2. Leads and develops sustainable performance and process improvement strategies to align care treatment and services with evidence-based experience-informed structures and processes.
3. Builds and defends the business case for Quality and Safety considering return on investment (ROI) regulatory or contractual requirements and strategic competitive advantages.
4. Creates an environment to review recommend and adopt best practices as part of quality safety regulatory and/or performance improvement.
5. Ensures practices policies and activities are in compliance with the requirements of relevant regulatory/licensing/oversight bodies; and ensures their readiness for associated review inspection reporting and application processes. This includes but is not limited to the Joint Commission and the Department of Public Health and the Centers for Medicaid and Medicare.
6. Facilitates development of priorities by: establishing criteria for priority assessment (volume risk problem prone processes); using data on past performance to assess gaps; using external drivers for consideration including new regulations and standards; and leveraging performance improvement tools to create a matrix for priorities to aid in decision making.
7. Establishes a learning system by fostering creativity encouraging spread of patient centric and evidence-based innovations.
8. Works in a variety of settings and determines key functions with the setting. Applies concepts of prioritization evidence-based practice and applicable performance monitoring tools.
9. Coaches and/or mentors individuals and teams in performance improvement strategies.
10. Improves the effectiveness and efficiency of the organizations processes and operations through consistent identification of risks to the organization. Works collaboratively with Risk Management.
11. Assesses designs and evaluates Patient Safety and Regulatory processes.
12. Leads the development and implementation of comprehensive strategies to minimize risks and establishes action plans to address problems when identified.
13. Uses evidence-based tools and strategies to implement advances and improvement of risk factors that affect the safe delivery of healthcare (i.e. Health IT adverse event reporting). Tools include Failure Mode and Effects Analysis (FMEA) Root Cause Analysis (RCA) Checklists project plans.
14. Analyzes and applies measures which are meaningful to project work.
15. Identifies and displays appropriate measures to evaluate process improvement efforts.
16. Works collaboratively with Quality Analytics and Applied Informatics.
17. Performs data analysis of qualitative and quantitative data review statistical reports identify data needs while maintaining attention to detail. May prepare data for regularly occurring committee/project meetings.
18. Assist with the intake process for new requests and basic data analysis for quality and safety related projects.
19. Facilitates analysis and interpretation of outcomes data for the organization.
20. May design and maintain dashboards for quality reporting and project and be able to perform basic troubleshooting of issues related to dashboards and reports.
21. Fosters an organizational culture of quality and safety including emphasis on an environment of psychologic safety.
22. Participates in regulatory survey procedures and works collaboratively with regulatory agencies and the community we serve.
23. Educates the management team related to functional interrelations associated with regulatory and accreditation requirements.
24. Participates actively in the organizations annual self - assessment of patient quality and safety through the Intracycle Monitoring Process (ICM).
25. Conducts tracer activities with Senior Leaders to support ongoing regulatory readiness and commitment in achieving the organizations performance standards.
26. Supports Medical Center committees as requested or required. Leads meetings of physicians nurses and caregivers related to project work.

All responsibilities are essential job functions.

II. Position Qualifications:

License/Certification/Education:
Required:
1. Masters degree in public health health care administration business administration or related area required or Bachelors degree required with employee currently enrolled in a qualified masters level degree program.

Preferred:
1. Clinical degree.
2. Certification in Healthcare and/or Quality.

Experience/Skills:
Required:
1. Five years related experience.
2. Strong knowledge of clinical processes and operations in a health care system.
3. Demonstrated leadership and project management skills proficiency in statistical quality control techniques operations analysis and quality management training.
4. Excellent verbal and written communication skills.
5. Exhibits strong analytical skills to perform data analysis of qualitative and quantitative data review statistical reports identify data needs while maintaining attention to detail.
6. Must be proficient in utilizing various computer software packages including word processing spreadsheets relational databases and graphic tools.

Unless certification licensure or registration is required an equivalent combination of education and experience which provides proficiency in the areas of responsibility listed in this description may be substituted for the above requirements.

All qualified applicants will receive consideration for employment without regard to race color religion sex sexual orientation gender identity national origin disability or protected veteran status.

Were striving to make respect a part of everything we do at UMass Memorial Health for our patients our community and each other. Our six Standards of Respect are: Acknowledge Listen Communicate Be Responsive Be a Team Player and Be Kind. If you share these Standards of Respect we hope you will join our team and help us make respect our standard for everyone every day.

As an equal opportunity and affirmative action employer UMass Memorial Health recognizes the power of a diverse community and encourages applications from individuals with varied experiences perspectives and backgrounds. All qualified applicants will receive consideration for employment without regard to race color religion gender sexual orientation national origin age disability gender identity and expression protected veteran status or other status protected by law.

If you are unable to submit an application because of incompatible assistive technology or a disability please contact us at We will make every effort to respond to your request for disability assistance as soon as possible.