I. General Summary

Under limited supervision, plans, coordinates, leads, and monitors quality improvement initiatives within clinical service departments and across the UMMC Downtown campus ("organization"). Communicates with organization leadership (Directors, Chairs, VPs, SVPs), clinical teams and other departments (Performance Innovation, Infection Prevention, Nursing, etc.) to drive organizational change toward high reliability and Zero Harm. Ensures awareness of, and continuously implements, the UMMC Quality Assurance/Performance Improvement (QAPI) program and the Annual Operating Plan (AOP) goals. Provides leadership and direction to multi-disciplinary teams (which include physicians and senior leaders) to collaboratively accomplish quality improvement strategies at UMMC. Accountable for overall quality of care provided to all patients in the designated 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 organization-wide committees. Promotes UMMC on its journey to become a High Reliability Organization (HRO) through the use of robust quality improvement tools and by promoting a Just Culture.

The position encompasses various roles (ex. subject matter expert, coordinator, educator, project manager, data analyst, and facilitator), and requires effective interpersonal, management and leadership skills. A working knowledge of clinical workflows and strong leadership skills are therefore integral to gaining credibility and collaboration from colleagues. Duties include working with UMMC clinical service departments on quality improvement strategies to 1) enhance clinical/patient outcomes, 2) maximize the organization's financial reward within the State of Maryland's pay for performance programs, and 3) optimize the organization's ranking within Vizient's Quality and Accountability (Q&A) dashboard. This role works with organization leadership, staff, advanced practitioners, and physicians to provide a planned, systematic, organization-wide approach to identify, measure, monitor, and evaluate quality improvement activities to foster a Zero Harm environment while promoting principles of a High Reliability Organization. This position develops and maintains interactive and collaborative relationships with key medical staff (including Chairs); collaborates with and provides structure and guidance to clinical service departments; and serves as a vital quality improvement resource to clinical teams and support staff including faculty, unit dyads, and front-line team members.

II. 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.

1. 1. Assists in the coordination and implementation of activities in the journey to become a high reliability organization with a focus on Zero Harm
   2. Collaborates with organization and Quality leadership to direct and implement the bi-campus, integrated quality improvement program including:
      1. Quality Program Management
         1. Oversees implementation of the quality improvement program for improving organizational performance. This includes planning, organizing, leading and directing clinical service department and organization-wide quality improvement activities by facilitating and leading multidisciplinary teams, which include physicians and senior leaders.
         2. Develops and leads projects of identified problem areas in accordance with organizational, department, and clinical service strategic priorities, including UMMC's QAPI program, AOP goals, the State of Maryland's pay for performance programs, and the Vizient Q&A dashboard. Occasionally, these projects may cross both campuses.
         3. Actively collects, reviews, analyzes and monitors organizational performance data to identify trends that may impact patient care and/or the organization's financial performance. Independently and in collaboration with organizational leadership and clinical service departmental leadership, identifies and prioritizes opportunities for quality improvement projects, evidence-based practice changes, and improved efficiencies based on the organization's performance and strategic priorities.
         4. Leads and manages special quality improvement projects by identifying resources needed, persons to be involved, and project management requirements necessary to complete the project. Occasionally, these projects may cross both campuses.
         5. Collaborates with organizational and departmental leadership to prioritize improvement efforts.
         6. In order to sustain improvements, responsible for ensuring action plans are implemented before handing-off to service line leaders for continued monitoring.
         7. Active participation (including membership or chair/co-chair role) in key organizational quality improvement committees, teams and projects including but not limited to: quality steering committees, diagnosis-specific committees (sepsis, heart failure, etc.), and/or clinical service department-specific committees (critical care, cardiac surgery, etc.). At times, these committees/teams/projects may cross both campuses.

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1. 1. 1. Leadership
         1. Works collaboratively with staff, senior leaders, clinical service department Chairs, and Lead Quality Physicians to identify and establish quality improvement priorities that align with UMMC's strategic initiatives, including but not limited to the QAPI program and the AOP goals.
         2. Partners with UMMC leadership to prioritize, facilitate and advance the ongoing focus on a culture of quality improvement and Zero Harm
         3. Facilitates clinical review and problem-solving processes through the use of quality improvement methodology and tools, including by not limited to: Root Cause Analysis (RCA), Plan Do Check Act (PDSA), Process Improvement methodology and Lean methods.
2. 1. 1. 1. Meets regularly with Lead Quality Physician in order to determine departmental and organizational quality focus and priorities; to review data to be presented at departmental quality improvement meetings; and to identify and present quality issues that need to be addressed.
         2. Develops and implements education for employees and medical staff to foster understanding of quality improvement methodologies and goals, including contributing to the bimonthly Quality Matters Newsletter.
         3. Provides just-in-time training on process and quality improvement tools and techniques to support executive champions, leaders and quality improvement teams.
         4. Keeps quality improvement teams on track with timelines and expected results based on the project charter.
3. 1. 1. Data Management
         1. Supports improvement work for the following metrics within the State of Maryland's pay-for-performance programs and/or the Vizient Q&A dashboard:
            1. Potentially Preventable Complications (PPCs)/Patient Safety Indictors (PSIs)
            2. Mortality
            3. Timely follow-up (TFU)
            4. Other metrics within the HSCRC's Quality Based Reimbursement program as deemed appropriate by Quality and organizational leadership and/or
            5. Other metrics that may impact the financial performance of the organization.
         2. Monitors quality indicators to identify trends and areas for improvement that are aligned with the organization's strategic objectives.
         3. Maintains and ensures accuracy of departmental and organization-wide dashboards (ex. the QSDR and the Quality Dashboard by Service) in collaboration with the Office of Healthcare Analytics and Informatics (OHAI).
         4. Independently and in collaboration with stakeholders, identifies trends or patterns that present an opportunity to improve the quality and safety of patient care. Occasionally, these trends or patterns may cross both campuses.
         5. Provides consultation to ancillary support and clinical departments within UMMC to establish quality indicators, analyze quality and utilization data, identify trends/patterns and formulate plans for resolving issues/problems.

1. 1. Provide leadership in the development and implementation of departmental and organizational strategies regarding regulatory compliance, including:
      1. Ensures 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.
      2. May participate and assist with organizational visits from accrediting agencies (TJC, CMS, etc.).
      3. May participate in organization-wide Joint Commission tracers, providing real-time staff education related to regulatory quality compliance and hospital policy requirements.
      4. May oversee actions taken in response to recommendations for improvement around quality deficiencies identified by regulatory agencies.