Director, Quality Management-UPMC York Memorial

UPMC•York, PA

8d•$57 - $85

About The Position

Directs the functions of the Quality Department to ensure high value, safety and quality of care and drive continuous process improvement. Accountable for all matters pertaining to the quality program at the assigned facility. The role serves as a resource for healthcare-acquired conditions, readmissions and patient safety indicators; analyzes events to identify improvement opportunities; and organizes, reports and maintains the peer review process. It develops and implements the individual quality plan in coordination with the Quality Department and ensures alignment with the strategic plan. The Director drives performance improvement measures and projects, develops solutions to address events, and supervises quality reporting related to reimbursement and quality ratings. The position serves as Patient Safety Officer, cultivates a strong safety culture, and develops and conducts safety activities. It ensures compliance with Joint Commission standards, Department of Health regulations and CMS Conditions of Participation, and coordinates surveys, audits and improvement activities. The role chairs the entity-level Environment of Care Committee, co-chairs the system-level committee, and maintains Environment of Care survey readiness. It develops and maintains the Patient Safety Plan, analyzes event reports for trends, and coordinates patient experience reporting and improvement plans. The Director is accountable for the Quality Department budget, including producing revenue and/or managing costs.

Requirements

Master’s degree required.
7–10 years of healthcare-related experience required.
Registered Nurse licensure in the Commonwealth of Pennsylvania required.
Familiarity with PDSA (Plan-Do-Study-Act) and DMAIC (Define-Measure-Analyze-Improve-Control) processes.

Nice To Haves

5–7 years of supervisor experience preferred.
Certification in a related area of expertise preferred.
Quality management experience preferred.

Responsibilities

Serve as a resource and support for healthcare-acquired conditions, readmissions and patient safety indicators; analyze events to identify improvement opportunities.
Organize, report and maintain the peer review process.
Develop and implement the individual quality plan, ensuring that it integrates with and supports the strategic plan in collaboration with the Quality Department.
Drive performance improvement measures and collaborate with departments to develop and implement performance improvement projects.
Develop and implement solutions to address events.
Supervise and maintain quality reporting related to reimbursement and quality ratings.
Serve as Patient Safety Officer; maintain a robust culture of safety and develop and conduct safety-related activities.
Ensure compliance with Joint Commission standards, Department of Health regulations and CMS Conditions of Participation.
Plan and coordinate survey activities, audits and improvement activities.
Chair the entity-level Environment of Care Committee and co-chair the system-level Environment of Care Committee; maintain survey readiness related to Environment of Care.
Develop and maintain the Patient Safety Plan; analyze event reports for patterns and trends to drive change and improvement in the patient safety program.
Coordinate patient experience reporting by analyzing data and driving implementation of improvement plans.
Manage the Quality Department budget, with accountability for producing revenue and/or managing costs.