Quality Safety Regulatory Project Manager - 40 hours, days

UMass Memorial Health-posted 8 days ago
$87,277 - $157,082/Yr
Full-time • Manager
Worcester, MA
5,001-10,000 employees
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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 20,000 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. Leads and manages UMass Memorial Medical Center- wide (UMMMC) quality, performance improvement, patient safety and regulatory compliance and sustainability efforts using a data-driven approach and which aligns with ongoing organizational strategic initiatives. Leads and performs activities in select departments and divisions, related to performance improvement in patient care. Scope of activities include quality and patient safety assessments, analyses, facilitation, information system solution identification, communication, and development and implementation of best practices.

  • Leads as a change agent, improvement advisor and facilitator. Manages change in a planned and productive manner.
  • Leads and develops sustainable performance and process improvement strategies to align care, treatment, and services with evidence-based, experience-informed structures and processes.
  • Builds and defends the business case for Quality and Safety considering return on investment (ROI), regulatory or contractual requirements, and strategic competitive advantages.
  • Creates an environment to review, recommend, and adopt best practices as part of quality, safety, regulatory and/or performance improvement.
  • 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.
  • 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.
  • Establishes a learning system by fostering creativity, encouraging spread of patient centric and evidence-based innovations.
  • 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.
  • Coaches and/or mentors individuals and teams in performance improvement strategies.
  • Improves the effectiveness and efficiency of the organization’s processes and operations through consistent identification of risks to the organization. Works collaboratively with Risk Management.
  • Assesses, designs and evaluates Patient Safety and Regulatory processes.
  • Leads the development and implementation of comprehensive strategies to minimize risks and establishes action plans to address problems when identified.
  • 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.
  • Analyzes and applies measures which are meaningful to project work.
  • Identifies and displays appropriate measures to evaluate process improvement efforts.
  • Works collaboratively with Quality Analytics and Applied Informatics.
  • 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.
  • Assist with the intake process for new requests and basic data analysis for quality and safety related projects.
  • Facilitates analysis and interpretation of outcomes data for the organization.
  • May design and maintain dashboards for quality reporting and project and be able to perform basic troubleshooting of issues related to dashboards and reports.
  • Fosters an organizational culture of quality and safety, including emphasis on an environment of psychologic safety.
  • Participates in regulatory survey procedures and works collaboratively with regulatory agencies and the community we serve.
  • Educates the management team related to functional interrelations associated with regulatory and accreditation requirements.
  • Participates actively in the organization’s annual self - assessment of patient quality and safety through the Intracycle Monitoring Process (ICM).
  • Conducts tracer activities with Senior Leaders to support ongoing regulatory readiness and commitment in achieving the organization’s performance standards.
  • 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.
  • Master’s degree in public health, health care administration, business administration or related area required, or Bachelor’s degree required with employee currently enrolled in a qualified master’s level degree program.
  • Five years related experience.
  • Strong knowledge of clinical processes and operations in a health care system.
  • Demonstrated leadership and project management skills, proficiency in statistical quality control techniques, operations analysis and quality management training.
  • Excellent verbal and written communication skills.
  • Exhibits strong analytical skills to perform data analysis of qualitative and quantitative data, review statistical reports, identify data needs, while maintaining attention to detail.
  • 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.
  • Clinical degree.
  • Certification in Healthcare and/or Quality.
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