Responsible for planning, coordinating, monitoring, and leading quality improvement initiatives within Perioperative and Procedural Services across both UMMC campuses, including data analysis, project management, and team facilitation to enhance patient outcomes, optimize financial performance, and improve hospital rankings. Partner with leadership and interdisciplinary teams to drive high reliability, patient safety, and regulatory compliance while fostering a culture of continuous improvement. Ensure continuous implementation of UMMC's Quality Assurance/Performance Improvement program, promote a Just Culture, and integrate best practices to sustain improvements in perioperative quality and safety. Work is performed under limited supervision. Direct report to the Vice President, Perioperative and Procedural Services.

Primary Responsibilities

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 responsibilities performed.

* Develop and oversee the perioperative quality improvement program, aligning efforts with hospital-wide initiatives, regulatory requirements, and annual operating plan goals.

* Lead multidisciplinary teams across both campuses to execute quality improvement projects that enhance clinical outcomes, efficiency, and patient safety.

* Collect, review, analyze, and monitor performance data to identify trends impacting patient care and financial performance.

* Collaborate with hospital and departmental leadership to prioritize quality improvement efforts, ensuring sustainability through effective action plans.

* Ensure ongoing compliance with quality and safety standards set by CMS, Joint Commission, and disease-specific certifications.

* Develop and implement strategies to reduce Potentially Preventable Complications (PPCs), Patient Safety Indicators (PSIs), surgical site infections, and hospital-acquired pressure injuries (HAPIs).

JOB DESCRIPTION

* Work with senior leadership, clinical department heads, and Lead Quality Physicians to establish and implement quality improvement priorities aligned with UMMC's strategic plan.

* Facilitate root cause analyses, Plan-Do-Check-Act (PDCA) cycles, and other process improvement methodologies to drive sustainable changes.

* Meet regularly with perioperative leadership and service line leads to review performance data, identify quality gaps, and develop targeted improvement strategies.

* Provide education and just-in-time training on quality improvement methodologies, high reliability principles, and performance improvement tools.

* Coach and mentor clinical leaders, staff, and physicians on quality and safety initiatives, fostering a culture of accountability and excellence.

* Actively participate in key hospital-wide quality committees, collaboratives, and strategic planning initiatives.

* Support the development of posters, presentations, and publications highlighting UMMC's quality improvement efforts at internal and external conferences.

* Lead initiatives to improve key quality metrics within Maryland's pay-for-performance programs and the Vizient Q&A dashboard.

* Monitor and ensure the accuracy of perioperative quality dashboards, providing actionable insights for leadership and clinical teams.

* Collaborate with Performance Innovation and other stakeholders to leverage data for continuous quality monitoring and improvement.

* Identify trends and opportunities for improvement in patient safety, efficiency, and compliance with accreditation and licensing standards.

* Support regulatory readiness efforts, including preparation for Joint Commission, CMS, and state health department surveys.

* Participate in hospital-wide tracers and provide real-time staff education on regulatory compliance and hospital policy requirements.

* Perform other duties as assigned