Under limited supervision, plans, coordinates leads and monitors quality improvement initiatives within clinical service departments and across both UMMC campuses. Communicates with hospital leadership (Directors, Chiefs, Chairs, VPs, SVPs), clinical teams and other departments (Performance Innovation, Infection Prevention, Nursing, etc.) to drive institutional 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 the hospital. Accountable for overall quality of care provided to all patients in the designated clinical service departments across both campuses, 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 (HRO) through the use of robust quality improvement tools and by promoting a Just Culture.

Encompasses various roles (ex. subject matter expert, coordinator, educator, project manager, data analyst, facilitator, and mentor). 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 across both campuses on quality improvement strategies to 1) enhance clinical/patient outcomes, 2) maximize the hospital's financial reward within the State of Maryland's pay for performance programs, and 3) optimize the hospital's ranking within Vizient's Quality and Accountability (Q&A) dashboard. Works with hospital leadership, staff, advanced practitioners, and physicians to provide a planned, systematic, hospital-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. Develops and maintains interactive and collaborative relationships with key medical staff (including Chairs and Chiefs); 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.

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. Applies expertise toward the coordination and implementation of activities in the journey to become an HRO with a focus on Zero Harm

2.Collaborates with hospital and Quality leadership to direct and implement the bi-campus, integrated quality improvement program including:

1. A. Quality Program Management:
   1. a) Develops and oversees implementation of the quality improvement program for improving hospital performance. This includes planning, organizing, leading and directing clinical services department and hospital-wide quality improvement activities by facilitating and leading multidisciplinary teams, which include physicians and senior leaders across both campuses. Develops and leads projects of identified problem areas in accordance with hospital, 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. These projects will frequently cross both campuses.
   3. b) 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.
   5. c) Leads and manages special quality improvement projects by identifying resources needed, persons to be involved, and project management requirements to complete the project. At times, these projects may cross both campuses.
   7. d) Collaborates with hospital and departmental leadership to prioritize improvement efforts.
   9. e) In order to sustain improvements, responsible for ensuring action plans are implemented before handing-off to service line leaders for continued monitoring
   11. f) Active participation (including membership or chair/co-chair role) in key hospital 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.). Frequently, these committees/teams/ projects may cross both campuses.

1. B. Senior Leadership Responsibilities:
   1. a) Works collaboratively with staff, senior leaders, clinical service department leadership (Chairs and Chiefs) and Lead Quality Physicians to identify annual quality improvement priorities that align with UMMC's strategic initiatives, including but not limited to the QAPI program and the AOP goals.
   3. b) Partners with UMMC leadership to prioritize, facilitate and advance the ongoing focus on a culture of quality improvement and Zero Harm.
   5. c) 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
   7. d) Meets regularly with Lead Quality Physicians to determine departmental and hospital quality focus and priorities; to review data to be presented at departmental quality meetings; and to identify and present quality issues that need to be addressed.
   9. e) 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.
   11. f) 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.
   13. g) Keeps quality improvement teams on track with timelines and expected results based on the project charter.
   15. h) Participates in improvement collaboratives with external organizations when opportunities arise
   17. i) Acts as a coach and advisor to physician and clinical leaders on processes and approaches to accomplish goals and achieve results.
   19. j) Collaborates with hospital and Quality leadership to develop posters and presentations for internal and external conferences as opportunities arise.
2. C. Data Management Responsibilities
   1. a) Responsible for 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 hospital leadership and/or
      5. Other metrics that may impact the financial performance of the hospital

b) Monitors quality indicators to identify trends and areas for improvement that are aligned with the hospital's strategic objectives.

c) Maintains and ensures accuracy of departmental and hospital-wide dashboards (ex. QSDR and Quality Dashboard by Service) in collaboration with the Office of Healthcare Analytics and Informatics (OHAI). .

d) Independently and in collaboration with stakeholders, identifies 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.

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