Director, Ambulatory Quality & Safety

General Summary

Under limited supervision, provides leadership and direction for patient safety and quality improvement strategies for University of Maryland Physician Network (UM PN). Works with leadership, staff and physicians to provide a planned, systematic, organization-wide approach to identify, measure, monitor, and evaluate safety and quality improvement activities. Ensures development of standards and application of benchmarking and best practice applications to support performance improvement at the service and organizational levels. Establishes goals and objectives aligned with the annual operating plan, including education, training, data management, and leadership. Develops and implements operating policies and procedures; interprets and ensures compliance with UM PN policies, quality standards, regulations and codes.

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. These are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

1. Provides leadership and direction for patient safety.

• A. Maintains a structure through which Patient Safety is continually assessed, evaluated, and improved. Ensures patient safety initiatives are coordinated.
• B. Oversees the care services in accordance with clinical protocols for review, reporting and improvement plans.
• C. Provides leadership in the ongoing focus on a culture of patient safety.
• D. Determines utilization of data to drive improvements in Patient Safety and minimize preventable harm.
• E. Facilitates a performance improvement approach for education at the practice level for employees and medical staff related to patient safety.
• F. Trending of patient and staff safety issues across practices and implements process improvement practices to address identified process failures.

2. Organizational Leadership: Provides leadership, support, oversight and coordination for the network quality improvement program. Plans additional performance improvement initiatives aligned with the UMMS Quality Management Strategy and/or other key business processes.

• A. Provides consultation to ancillary support and clinical departments within the Physician Network to establish quality indicators, analyze quality data, identify trends/patterns and formulate plans for resolving issues/problems.
• B. Directs the processes that provide relevant data, reports, and education to support a continuous quality improvement environment. Evaluates and revises the Quality Improvement Program to reflect current developments, national trends, and best practices as reflected in PQRS, Meaningful Use, MIPS, and other federal quality programs.
• C. Ensures provisions of regular and comprehensive quality reporting including targets, trends and regulatory requirements, case specific data, and information flow requirements in accordance with Plan for Improving Organization Performance.

3. Change Leadership: Supports the structure, organization and culture for continuous quality and operations improvement. Initiates and facilitates redesign and process improvement strategies for strategically important priorities within the organization. Creates detailed, comprehensive project and action plans and timelines to ensure successful execution of programs. Develops quantifiable metrics to measure return on investment (ROI) and effectiveness. Monitors and measures results; develops standards and applies benchmarking and best practice applications to support improvement at the team and organizational levels. Acts as a consultant and advisor to leadership to build consensus and support for process improvement initiatives at an organizational level. Researches and remains current on process improvement opportunities, and methodologies appropriate for a healthcare environment. Provides training and education to support process improvement initiatives in the organization. Consults with organizational learning and development and designs educational curriculums and programs to support leadership, medical staff and employee education and training to participate in process improvement initiatives. Mentors and supports performance improvement staff and other organizational leaders and change efforts to support their development and improvement efforts. Assists leaders and teams to facilitate major change and organization improvement.

4. Process Improvement Leadership: Serves as expert on performance improvement tools and techniques. Leads and/or facilitates process improvement teams to achieve significant quality improvement and business results in a manner which gives them ownership for changes. Works with executive champions and physician leaders to facilitate performance improvement teams and achieve timely results consistent with strategic and operational goals and to create a charter focused on group process steps, meeting planning and results with specific timelines and goals for the team. Provides just-in-time training on process improvement tools and techniques to support executive champions, leaders and performance improvement teams. Acts as a coach and advisor to the executive champions, and leaders on processes and approaches to accomplish goals and achieve results. Keeps the executive champion, leader, and performance improvement team on track with timelines and expected results based on the charter. Collects and analyzes data to evaluate operational difficulties and makes recommendations to solve problems. Identifies inefficiencies, analyzes and reports solutions to correct inefficiencies. Coordinates staff and resources in reporting and non-reporting relationships.

5. Ensures compliance with Regulatory Requirements related to Quality and Patient Safety. Ensures compliance with external regulators and accrediting agencies, if applicable (e.g., The Joint Commission, CMS, Maryland State Department of Health and Mental Hygiene) and compliance for special designations (e.g. PARC).

• A. Ensures that Medical Group and department policies, procedures and standards meet requirements and regulations of regulatory and accrediting agencies.
• B. Ensures participation in State and Federal quality projects as applicable to obtain comparative data on quality indicators

6. Staffs or participates in key committees related to Quality and Safety.

Education and Experience

1. Bachelor’s degree in Health Care Administration, Business, or related field is required; Masters preferred. Equivalent experience with hospital or ambulatory quality measures may be substituted required for education.
2. Five (5) years of progressively responsible experience performing quality improvement is required. Experience must include development of new and innovative quality initiatives with a focus on physician partnerships.
3. Five (5) years leadership experience in healthcare quality and patient safety in an acute care facility is required.
4. Registered Nurse or other allied health related field professional with current license to practice in Maryland.
5. Certified Professional in Healthcare Quality (CPHQ) preferred.

Knowledge, Skills and Abilities

1. Comprehensive knowledge of federal, state and local requirements of regulatory and accreditation agencies is required.
2. Proficient knowledge of quality improvement measurement, analysis and improvement strategies is required.
3. Strong leadership and interpersonal skills are required.
4. High level of proficiency in directing and evaluating the performance of professional staff is required.
5. High level of proficiency and demonstrated effectiveness in problem-solving, analytical skills and implementation of new programs to increase departmental and organizational operating efficiency.
6. Highly effective oral and written communication skills are required to work with all levels of hospital personnel, administrators and clinical staff as well as outside agencies.
7. Computer skills: AccessExcel, PowerPoint, MS Word - Intermediate Level
8. Excellent Organizational Skills
9. Ability to lead, coach and persuade others as needed to accomplish projects
10. Ability to work with statistical concepts and analysis
11. Knowledge of organization and leadership development concepts and tools.

Salary : $1 - $1,000,000