Director, Quality, Patient Safety, Regulatory & Infection Prevention

UPMC•Monroeville, PA

About The Position

UPMC is seeking a dynamic and experienced Director of Quality, Patient Safety, Regulatory & Infection Prevention to provide strategic leadership and operational oversight for quality, patient safety, and patient experience initiatives across UPMC East and UPMC McKeesport. This role leads two integrated teams, totaling approximately 10 professionals, and plays a key part in advancing UPMC’s commitment to exceptional care and continuous improvement.

Requirements

Master's Degree in nursing, healthcare administration, public health or other relevant field required.
5 years of progressively responsible experience in health care including supervision and leadership required
Knowledge of various aspects of quality and process improvement, extensive experience in implementation systems and other techniques required.
Experience in effective presentation of quality efforts to board, executives, and multiple disciplines.
Demonstrated Leadership qualities knowledge of Clinical Practices Knowledge of regulatory requirements of multiple accrediting organizations including TJC, DOH, and CMS Advanced analytic skills.
Advanced interpersonal communications skills to assure a collaborative positive culture.
Ability to effective and succinctly communicate verbally and in writing to all levels of the organization.
Flexible, adaptable, and open to change.
Act 34

Nice To Haves

Master’s degree required (nursing background strongly preferred).
5 year of progressive experience in health care, with demonstrated success in quality, patient safety, or performance improvement.
Prior senior leadership experience in a healthcare setting is highly desirable.
Proven expertise in quality metrics, data interpretation, and performance improvement methodologies.
Exceptional communication, relationship‑building, and presentation skills.
RN licensure strongly preferred

Responsibilities

Provide input into CQSI data analytics development and reports.
Develop, implement, or utilize appropriate existing system data management capability that supports clinical program initiatives, decision support and regulatory compliance.
Serves as the local leadership contact, in conjunction with Patient Safety staff, for the UPMC Risk Management department and collaborates as such.
Coach and advise professional staff in the formulation of their development plan.
Manage all human and financial aspects of the department to assure that standards for quality and cost effectiveness are met. Prepare annual man-hours; expense and capital budget for responsible cost centers based on an analysis of needs of patients, clinical programs, staff and physicians.
Demonstrate an interactive leadership style that influences thinking and reshapes the quality environment.
Lead multidisciplinary teams, as assigned, in the development and ongoing progress of clinical outcomes to achieve organizational objectives of reducing resource utilization while promoting quality patient outcomes.
Provide administrative oversight for Infection Control including surveillance, data collection, education, and collaboration to reduce HAI's.
Recommend changes to policies and procedures to senior leadership. Provide oversight of Policy and Procedure Committee and the revisions and improvements to the process.
Develop relationships and integrate all team members including physicians into the team's work. Report program findings, results, and changes at various settings and meetings. Form relationships with various setting in the continuum of care based on program issues/work.
Provide collaborative leadership on a consistent basis that smooth the interface points within the complex matrix environment that includes UPMC, employed physicians, private practice, and multiple clinical sites.
Collaborate with professionals across UPMC to identify and support joint educational opportunities to change clinical practice. Active participation on System Quality, Safety, Regulatory, Infection Control, and Patient experience teams.
Responsible for ensuring implementation of a Patient Experience /Relations Program.
Works collaboratively with CQSI to ensure current and future obligations are met with respect to Public Reporting of quality outcomes.
Demonstrate initiative to address complex, high-risk problems and translate them into opportunities and challenges with all levels of management.
Ensure budgetary standards/expectations are met by monitoring and maintaining expenses and man-hour utilization.
Provides administrative leadership and overall direction to the Quality, Patient Safety, Regulatory, Infection Control, and the Patient Experience functions.
Complete performance reviews to maintain compliance.
Assume leadership role in the development of process improvement opportunities related to changes in clinical practice to support organizational goals. Apply innovative and creative skills to ensure that the process improvement opportunities are identified and addressed as well as meet the needs of quality and safety goals, and meets regulatory guidelines.
Serves as Facility Contact for PHC4 and PHCQA.
Provide leadership and preparation for Regulatory Compliance including DOH Licensure and Joint Commission Accreditation Surveys
Effectively participate and engage in activities to support and achieve organizational strategic goals including an analysis of quality programs and patient care outcomes.
Make decisions and evaluate outcomes with adequate knowledge, information and consideration of physician stakeholders and members of the all departments.
Conduct an analysis of clinical variance trends and recommendations for clinical practice changes. Investigate and implement creative methods to improve process.
Implement programs and activities, which support the organization's quality goals. Provide oversight for all appropriate UPMC pay for performance programs.
Demonstrate responsiveness to the changing priorities and targets in the field of quality and patient safety, and patient experience.
Serve as the senior internal consulting resource for clinical measurement, analysis and reporting.
Demonstrate a collaborative leadership role in the External Regulatory Survey process, to ensure compliance and continual readiness for accreditation and licensure surveys.
Responsible for the development, regulatory requirements, and clinical pathways of the stroke population and program.
Oversight of the privacy officer function: Responsible for quarterly rounding on all areas of the hospital, investigation of all situations that could be in violation, and participating in HR meetings related to privacy.