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Serves as the expert for Performance Improvement, Accreditation, and the Patient Safety program. Responsibilities include oversight for regulatory compliance related to Hospital Quality Reporting and regulatory submissions to CMS, (mortality reduction, readmission reduction, safety of care, complications) as well as leadership over the patient safety programs (Variance Reporting System, event investigation, mortality review, and investigations and responses to outside entities as required). Organizes and leads accreditation preparedness and surveys. Provides input, through data and analysis to strategic decisions that affect patient safety. Works collaboratively with organizational leaders and medical staff to identify and address factors that may contribute to adverse patient outcomes or harm. Through the work of the Performance Improvement Committee, implements the organization’s quality and patient safety plan and serves as a catalyst within the system to move the organization forward; supporting a strong patient safety culture and high reliability processes.

Reports to

Senior Vice President Quality and PI

Job Specific Responsibilities

Healthcare Reform

- Responsible for providing leadership and coordination of external benchmarking, clinical database and registry activities related to outcomes data collection,
- validation, aggregation and reporting to meet hospital, quality improvement initiatives
- Serve as the expert resource on CMS Affordable Care Act Programs specific to Hospitals (IQR,
- OQR, eCQM, Hospital Value Based Program (HVBP), Hospital Readmission Reduction Program
- (HRRP), Hospital Acquired Condition Reduction Program (HACRP) and applicable State
- requirements,
- Keeps abreast of regulatory requirements, qualified standards and competitive industry
- practices, as well as organizational initiatives with potential to impact current strategies.
- Provides program oversight for hospital quality measures. Ensures that all quality data submissions for regulatory agency deadlines are completed in a timely and accurate manner.
- Provides ongoing dissemination and assessment of performance and clinical outcome data to identify improvement opportunities and/or trends through aggregation and summation of data.
- Identifies quality improvement opportunities through analysis of facility and external benchmark data.
- Develops, evaluates, and maintains quality dashboards and performance metrics.
- Supports the work of the ACO/CIN through the Hospital Quality and Efficiency Program (HQEP) and the PI Committee.
- Coordinate and oversee the hospital Quality Improvement Plan (review, revision, and implementation).

Accreditation

- Lead accreditation readiness and compliance activities by overseeing organizational adherence to regulatory and accreditation standards, coordinating surveys, and ensuring continuous survey preparedness across all hospital departments.
- Monitor and evaluate compliance performance through audits, tracers, mock surveys, and data analysis; identify gaps, implement corrective action plans, and track sustainable improvement.
- Partner with clinical and operational leaders to interpret standards, implement evidence-based practices, and integrate accreditation, designation and verification requirements into daily operations and quality improvement initiatives.
- Provide education and guidance to leaders and staff on accreditation, designation and verification standards, regulatory updates, documentation requirements, and compliance expectations to support a culture of continuous readiness and patient safety.

Patients Safety

- Proactively engages with individual staff, teams, and services to improve safety, quality and efficiency of care. Utilizes a wide range of analytical and evaluative methods and techniques in providing consultation regarding HRO and patient safety that supports the mission, vision, values, strategic plan and organizational priorities.
- Lead organizational patient safety initiatives to reduce medical errors and preventable harm through data-driven improvement, variance reporting, and continuous monitoring of progress toward zero avoidable harm.
- Promote a culture of safety and learning by sharing lessons from patient events, participating in PSO collaborations, implementing best practices, and providing ongoing education on high reliability and patient safety principles.
- Drive sustainable performance improvement through process evaluation, internal audits, accountability measures, and implementation of corrective actions that strengthen systems and improve patient outcomes

📌 Director Process Improvement (Bluesky)
🏢 UMC Health System
📍 Bluesky