Mgr, Quality & Safety,Dept (L)

As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive.

Job Location (Full Address):

Remote Work - New York, Albany, New York, United States of America, 12224

Opening:

Worker Subtype:

Regular

Time Type:

Full time

Scheduled Weekly Hours:

40

Department:

500027 Quality Improvement

Work Shift:

UR - Day (United States of America)

Range:

UR URG 113

Compensation Range:

$77,216.00 - $115,824.00

Responsibilities:

The Quality, Safety and Patient Experience Director, in coordination with Orthopaedic leadership, will proactively develop, lead, and drive the execution of Quality, Regulatory, and Clinical Safety strategies with a focus on collaboration and innovation while balancing the Institute’s needs with regulatory compliance. This director will maintain overall responsibility for leading quality initiatives, including setting quality goals, and managing and improving all aspects of patient safety, quality, and patient experience across the service line. The Director will support leadership, education, and project management using the Musculoskeletal Service Line’s Quality and Performance Improvement Plans to improve quality, support operational clinical initiatives, promote innovation, and identify/develop best practices for clinical excellence, service excellence, and patient safety. The Musculoskeletal Service Line encompasses the clinical activities of several departments at SMH, HH, FF Th, FLH, NMH, JMH, and SJM.

ESSENTIAL FUNCTIONS

Quality:

• Collaborates with the institute's senior leadership team on strategic initiatives and performance improvement goals
• Ensures Orthopaedic and Musculoskeletal Service Line objectives are aligned across the service line, and the institute is achieving quality objectives
• Utilizes, integrates, and interprets data (e.g. PROMIS, NSQIP, Vizient, etc.) to assist the Musculoskeletal Service Line in its improvement efforts, promotes optimal patient outcomes, optimizes reputation, increases quality of care, and reduces reputational risk while reducing disparities in care
• Continuously evaluates work process and design; understands the role in ensuring quality/performance improvement, productivity, and service delivery to meet the institute's stakeholder needs
• Participates in and coordinates quality reviews to both drive safety and outcomes, and for regulatory compliance
• Collaborates with system-wide (SMH, HH, FF TH, FLH, NMH, JMH, SJM) quality and safety leaders to identify and fulfill data requirements. Develops and maintains system-level dashboards by integrating data from multiple sources, including CMS and Vizient, ensuring comprehensive and actionable insights.
• Partners with data programmers and IT teams to design and sustain accurate data pulls, verifying the appropriateness of variables and calculations used. Establishes and promotes the use of standardized "Blue-Ribbon" variables and measures to ensure consistency and reliability in report development.
• Actively engages hospital and system leaders in data review processes during relevant meetings to drive informed decision-making.
• Coordinates the development of ad hoc reports by working closely with clinical and operational leaders to understand specific data needs and address any limitations stemming from data collection methods or workflow constraints. Ensures that report results are complete, accurate, and easily interpretable. Designs clear and effective visualizations to facilitate accurate data interpretation and actionable insights.
• Act as liaison between department faculty and OCMC and Risk Management.
• Manages registry measure validation and quality testing, collaborating with IT, Registry, and Quality staff to implement validation requirements.
• Provides education to providers, staff, and trainees in quality science and process improvement techniques, and encourages stakeholder engagement
• Participates in and facilitates the Quality Coordinating Council, Perioperative Quality Council, Orthopaedics Quality Committee, and any associated divisional quality meetings, programs, and initiatives.

Patient Safety:

• Actively contributes to and works toward institute-wide improvement in meeting strategic measures, patient safety, and service excellence goals
• Deploys established methodology (e.g. RCA, FMEA, lean, gap analysis) to analyze and improve safety and optimize clinical workflows aligning operational efficiency and quality.  Monitor similar analyses across the regional service line.
• Work collaboratively with Patient Family services on grievances that are received from an Orthopaedic patient who received care while either in the clinic and/or under care in the OR.

Patient Experience:

•  Lead efforts to drive meaningful improvements in patient experience by collaborating with leadership to identify, prioritize, and implement strategic initiatives. Provide oversight and direction for the Patient Experience program, including efforts to enhance patient satisfaction, address complaints, and resolve grievances effectively.
• Conduct comprehensive analysis of internal and external customer satisfaction metrics and performance analytics to monitor trends, identify areas for improvement, and develop actionable plans to enhance outcomes.
• Support URMC hospital programs by designing and analyzing dashboards, generating detailed reports, and recommending strategies to improve reporting accuracy and quality performance metrics.
• Oversee responses to third-party payer inquiries related to patient concerns, ensuring timely and effective resolution.
• Partner with the URMC Patient Experience Office to develop and facilitate the Patient and Family Advisory Council, fostering collaboration and engagement to improve patient-centered care initiatives.
• Participate in inpatient unit quality rounds.

Compliance:

• Lead efforts to monitor, evaluate, and enhance clinical protocols, practices, and management guidelines. Conduct audits, case reviews, and trend analyses to ensure compliance with quality indicators and drive continuous improvement.
• Develop and implement procedures to maintain required certifications and verification standards, ensuring adherence to regulatory criteria and national benchmarks.
• Oversee the design and maintenance of specialty registries, ensuring data integrity and accuracy for performance improvement, reporting, and research purposes.
• Facilitate communication and cooperation among healthcare disciplines, external stakeholders, and regulatory bodies. Build positive relationships with physicians, referring hospitals, and community partners.
• Coordinate and deliver training programs for healthcare providers, including onboarding, specialty service meetings, and educational courses to support certification and improve care standards.
• Assist in developing and maintaining business plans, including benchmarking analysis, budget objectives, and long-term strategic goals to support program growth and sustainability.
• Assist department leadership in the design, administration, and monitoring of yearly MCIC initiatives.

Other duties as assigned

MINIMUM EDUCATION & EXPERIENCE

• Bachelor of Science in Nursing or equivalent graduate training or experience in a specialty suited to the assignment required. 
• 8 years relevant work experience including substantial work at a managerial level, preferably in a healthcare setting; equivalent combination of education and experience required.
• Experience with quality assurance and quality improvement processes is an advantage required.
• Minimum of 5 years of clinical experience or equivalent combination of education and experience required.
• Experience with Joint Commission, CMS and NYSDOH continuous survey readiness preferred
• Experience with quality initiatives in clinical settings required
• Minimum of 5 years of experience in a quality management role preferred

KNOWLEDGE, SKILLS AND ABILITIES

• LEAN preferred

LICENSES AND CERTIFICATIONS

• Certified Professional in Healthcare Quality (CPHQ), or Certified Professional In-Patient Safety (CPPS) desired

The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture to advance the University’s Mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion, creed, sex, sexual orientation, citizenship status, or any other characteristic protected by federal, state, or local law (Protected Characteristics). This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law.