Manager, Quality Improvement

Job Description

Under limited supervision, leads the Quality Improvement team in the mission of improving clinical quality at UMMC. Responsible for planning, coordinating, leading and monitoring quality improvement initiatives across the organization and within clinical service departments, frequently across both campuses.  In coordination with the Senior Director, the Manager is responsible for ensuring the Quality Improvement team is deployed appropriately to drive quality improvement throughout the organization, utilizing quality improvement methodologies and tools to drive sustainable improvement in organizational and local strategic initiatives. This includes ensuring the team is aware of, and continuously implements, the UMMC Quality Assurance /Performance Improvement (QAPI) program and the Annual Operating Plan (AOP) goals. Accountable for overall quality of care provided to all patients in clinical service departments, as well as compliance with quality requirements as outlined by CMS, Joint Commission, and/or disease specific certifications.  Collects and analyzes data, conducts presentations, provides consultation, and 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.

Provides local, structural leadership to the UMMC Downtown Campus Quality Improvement Team, while functionally supporting initiatives across both campuses. Provides guidance and general direction for Quality department operations, ensuring accurate and timely production of work. Provides mentorship for Quality Improvement staff in the delivery of their work to drive the strategy of the organization. Attends organizational meetings as a representative of the Quality & Safety department to help ensure regulatory quality compliance and improvement standards are met.

Provides leadership and direction for quality improvement strategies across both campuses, including but not limited to the annual review and implementation of the UMMC Plan for Improving Organizational Performance.

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 the hospital's strategic 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, which may cross both campuses.

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.

Facilitates the development of Clinical Practice Guidelines (CPGs) and establishes metrics for tracking and monitoring CPG adherence and impact.

Actively collects, reviews, analyzes and monitors hospital performance data related to identify trends that may impact patient care and/or the hospital’s financial performance. Independently and in collaboration with hospital leadership and clinical service department leadership, identifies and prioritizes opportunities for quality improvement projects, evidence-based practice changes, and improved efficiencies based on the hospital’s performance and strategic priorities.

Partners with UMMC leadership to prioritize, facilitate and advance the ongoing focus on a culture of quality improvement and Zero Harm.

Collaborates with hospital and Quality leadership to develop posters and presentations for internal and external conferences as opportunities arise.

Responsible for oversight of the team’s bi-campus improvement work for the following metrics within the State of Maryland’s pay-for-performance programs and/or the Vizient Q&A dashboard:Potentially Preventable Complications (PPCs)/Patient Safety Indicators (PSIs)

Mortality

Timely Follow-up (TFU)

Other metrics within the HSCRC’s Quality Based Reimbursement program as deemed appropriate by Quality and hospital leadership and/or

Other metrics that may impact the financial performance of the hospital.

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.Collects, reviews and analyzes data related to quality improvement and clinical care, and identifies strategies and opportunities for evidence-based practice and efficiency improvements. 

Works collaboratively with Clinical Service Department Chairs and Chiefs, Lead Quality Physicians, and with staff and leaders to identify quality improvement priorities.

Works collaboratively with the Office of Healthcare Analytics and Informatics (OHAI) to develop comprehensive departmental dashboards. Engages in analysis of quality data to identify trends or patterns that present an opportunity to improve the quality and safety of patient care. Frequently, these trends or patterns may cross both campuses.

Facilitates clinical review and problem-solving processes through the use of robust quality improvement methodology and tools, including but not limited to: Root Cause Analysis (RCA), Plan Do Check Act (PDSA), Process Improvement methodology and Lean methods. 

Leads and manages special quality improvement projects by identifying resources needed, persons to be involved, and project management requirements to complete the project. Frequently, these projects may cross both campuses. 

Participates in improvement collaboratives with external organizations when opportunities arise.

In order to sustain improvements, responsible for ensuring action plans are implemented before handing-off to service line leaders for continued monitoring.

Provide leadership in the development and implementation of departmental and organizational strategies regarding regulatory compliance.Ensures the Downtown Campus’ compliance with regulatory standards within the Joint Commission Performance Improvement (PI) Chapter and the CMS Condition of Participation (42 CFR 482.21) related to the organization’s QAPI program.

May participate and assist with organizational visits from accrediting agencies (TJC, CMS, etc.) at both campuses.

May participate in organization-wide Joint Commission tracers, providing real-time staff education related to regulatory quality compliance and hospital policy requirements.

May oversee actions taken in response to recommendations for improvement around quality deficiencies identified by regulatory agencies.

May complete specific regulatory compliance activities with an effort to drive quality improvement.

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.

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