Job Facility: University of Maryland Medical Center
Employment Type: Full Time
What You Will Do:
Under limited supervision, plans, coordinates and leads quality improvement and patient safety initiatives for clinical service departments and across the organization. Accountable for overall quality of care provided to patients in clinical service departments, as well as compliance with requirement by CMS, Joint Commission, and disease specific certifications. Collects and analyzes data, conducts presentations, provides consultation, staffs and leads service specific and hospital-wide committees. Promotes UMMC on its journey to become a High Reliability Organization through its use of robust process improvement tools and promoting a just safety culture.
Principal Responsibilities and Tasks The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.
Plans, organizes, and directs clinical services’quality improvement and patient safety activities. Conducts studies of identified problem areas in accordance with organizational, department, and clinical service priorities.
Works collaboratively with Clinical Service Department Chairs and Quality Physicians and with staff and leaders to identify quality improvement and patient safety priorities.
Collects, reviews and analyzes data related to quality improvement and clinical care, and identifies strategies and opportunities for evidence based practice and efficiency improvements.
Meets regularly with departmental quality management physicians and staff in order to formulate agenda for department quality management meetings; determine departmental quality focus and priorities; review data to be presented at departmental quality management meetings; and present quality issues that need review.
Initiates review of cases regarding patient care quality, safety, and compliance issues, making recommendations to physicians, department managers, administration and committees for corrective actions.
Maintains and assures accuracy of departmental dashboards in collaboration with Clinical Decision Support Department and the Data Scientist. Prepares statistical reports as required for medical staff, quality management committees and quality task forces to identify trends or patterns that present an opportunity to improve the quality and safety of patient care.
Facilitates clinical review and problem-solving processes through the use of robust quality improvement methodology and tools, to include Root Cause Analysis (RCA), Plan Do Check Act (PDSA), and Lean methods.
Leads and coordinates special quality improvement projects and studies. Identifies resources needed, persons to be involved and project management aspects of accomplishing the project. Participates in improvement collaboratives with external organizations when opportunities arise. Responsible for assuring monitoring of action plans in order to sustain improvements.
Leads, coordinates, and supports organization-wide quality and safety improvement activities to achieve significant quality improvement and business results in a manner which gives each stakeholder ownership for changes.
Monitor quality indicators to identify trends and areas of opportunity for improvement that are aligned with hospital objectives.
Facilitates multidisciplinary teams using improvement tools to achieve improved quality care.
Provides just-in-time training on process and quality improvement tools and techniques to support executive champions, leaders and quality improvement teams.
Act as a coach and advisor to physicians and clinical leaders on processes and approaches to accomplish goals and achieve results.
Keeps quality improvement teams on track with timelines and expected results based on the charter.
Collects and analyzes data to evaluate opportunities and makes recommendations to solve problems.
Provide leadership in the development and implementation of departmental and organizational strategies regarding regulatory compliance.
Participates and assists with organizational visits from accrediting agencies.
Participates in organization-wide Joint Commission tracers, monitoring and educating staff in regulatory compliance and hospital policy requirements
Oversees reviews and actions taken in response to recommendations for improvement and deficiencies identified by regulatory agencies and by patient complaints.
Works with providers to monitor and promote quality improvement activities related to clinical documentation in the medical record.
Provides consultation to ancillary support and clinical departments within the organization to establish quality indicators, analyze quality and safety issues, identify trends, patterns, and formulate plans for resolving issues/problems.
What You Need to Be Successful:
Education and Experience
Master’s degree in Nursing or other Health Care field is required.
Current licensure in Nursing or related field is required (i.e. nursing, physical therapy).
Five (5) years of progressively responsible professional experience performing Quality Management activities, or equivalent is required. Two (2) years of lead/supervisory experience is required.
Knowledge, Skills and Abilities
Demonstrated broad based knowledge of improvement methodology and ability to coach and lead staff. Ability to facilitate and lead clinical quality improvement and the problem-solving process in a clinical setting.
Must possess the ability to effect change among groups from various departments, to coordinate/prioritize information and activities, and to problem solve.
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. Knowledge of quality improvement and risk management is required. Familiarity with physician practice standards, and legal and ethical practices
Highly effective verbal and written communication skills are necessary to work with medical, nursing staff and external review agencies in monitoring and evaluating the quality of patient care
Ability to assess safety, quality, and regulatory compliance problems, recommend solutions, and resolve issues in a timely, efficient, and effective manner.