Job Description

Job Title: Director, Quality, Safety and Experience - UPMC Passavant & UPMC St. Margaret
Job ID: 694006
Status: Full-Time
Regular/Temporary: Regular
Hours: Daylight, Monday thru Friday
Shift: Day Job
Facility: UPMC St. Margaret
Department: Quality and Risk Mgmt
Location: 815 Freeport Road, Pittsburgh PA 15215


Are you a seasoned healthcare leader with a background in quality, safety, infection control, or patient experience? Are you looking to expand your scope in a unique position overseeing related functions across two Magnet-designated hospitals? This could be the perfect opportunity for you!

UPMC St. Margaret, together with UPMC Passavant, seeks a full-time Director of Quality, Safety, and Experience to support our hospital and outpatient campuses.

UPMC St. Margaret is a 249-bed acute care and teaching hospital situated on a 21-acre campus near Aspinwall (Pittsburgh). It begins its second century of service with renewed dedication to more than 250,000 residents of northeastern Allegheny County and the Alle-Kiski Valley, providing residents convenient access to the area’s finest physicians and health services. UPMC St. Margaret also includes our affiliated outpatient centers in the surrounding area.

UPMC Passavant serves as UPMC’s tertiary care center north of Pittsburgh, bringing UPMC’s brand of world-class medical care to two convenient campuses in McCandless and Cranberry Townships to serve the communities and counties north of the city. Advanced, high-quality care and all of the resources of an academic medical center are available closer to residents north of Pittsburgh. 

Both UPMC St. Margaret and UPMC Passavant are Magnet designated hospitals. Magnet status is one of the the highest achievements an organization can obtain for nursing excellence and leadership. Only 6.8 percent of hospitals nationwide have received Magnet status.

As Director, you will provide administrative leadership and overall direction to the Quality, Patient Safety, Regulatory, Infection Control, and the Patient Experience functions at our hospitals. You will lead a team of direct reports who manage each of these core functions.

A highly visible role, this position will report directly to the CNO, VP of Patient Care Services at UPMC St. Margaret, and also to the CNO, VP of Patient Care Services & VP of Operations at UPMC Passavant.

Are you interested? Apply today!

  • Assume leadership role in the development of process improvement opportunities related to changes in clinical practice to support organizational goals. Apply innovative and creative skills to ensure that the process improvement opportunities are identified and addressed as well as meet the needs of quality and safety goals, and meets regulatory guidelines.
  • Coach and advise professional staff in the formulation of their development plan.
  • Collaborate with professionals across UPMC to identify and support joint educational opportunities to change clinical practice. Active participation on System Quality, Safety, Regulatory, Infection Control, and Patient experience teams.
  • Complete performance reviews to maintain compliance.
  • Conduct an analysis of clinical variance trends and recommendations for clinical practice changes. Investigate and implement creative methods to improve process.
  • Demonstrate a collaborative leadership role in the External Regulatory Survey process, to ensure compliance and continual readiness for accreditation and licensure surveys.
  • Demonstrate an interactive leadership style that influences thinking and reshapes the quality environment.
  • Demonstrate initiative to address complex, high-risk problems and translate them into opportunities and challenges with all levels of management.
  • Demonstrate responsiveness to the changing priorities and targets in the field of quality and patient safety, and patient experience.
  • Develop relationships and integrate all team members including physicians into the team's work. Report program findings, results, and changes at various settings and meetings. Form relationships with various setting in the continuum of care based on program issues/work.
  • Develop, implement, or utilize appropriate existing system data management capability that supports clinical program initiatives, decision support and regulatory compliance.
  • Effectively participate and engage in activities to support and achieve organizational strategic goals including an analysis of quality programs and patient care outcomes.
  • Ensure budgetary standards/expectations are met by monitoring and maintaining expenses and man-hour utilization.
  • Implement programs and activities, which support the organization's quality goals. Provide oversight for all appropriate UPMC pay for performance programs.
  • Lead multidisciplinary teams, as assigned, in the development and ongoing progress of clinical outcomes to achieve organizational objectives of reducing resource utilization while promoting quality patient outcomes.
  • Make decisions and evaluate outcomes with adequate knowledge, information and consideration of physician stakeholders and members of the all departments.
  • Manage all human and financial aspects of the department to assure that standards for quality and cost effectiveness are met. Prepare annual man-hours; expense and capital budget for responsible cost centers based on an analysis of needs of patients, clinical programs, staff and physicians.
  • Provide administrative oversight for Infection Control including surveillance, data collection, education, and collaboration to reduce HAI's.
  • Provide collaborative leadership on a consistent basis that smooth the interface points within the complex matrix environment that includes UPMC, employed physicians, private practice, and multiple clinical sites.
  • Provide input into CQSI data analytics development and reports.
  • Provide leadership and preparation for Regulatory Compliance including DOH Licensure and Joint Commission Accreditation Surveys
  • Provides administrative leadership and overall direction to the Quality, Patient Safety, Regulatory, Infection Control, and the Patient Experience functions.
  • Recommend changes to policies and procedures to senior leadership. Provide oversight of Policy and Procedure Committee and the revisions and improvements to the process.
  • Responsible for ensuring implementation of a Patient Experience /Relations Program.
  • Serve as the senior internal consulting resource for clinical measurement, analysis and reporting.
  • Serves as Facility Contact for PHC4 and PHCQA.
  • Serves as the local leadership contact, in conjunction with Patient Safety staff, for the UPMC Risk Management department and collaborates as such.
  • Works collaboratively with CQSI to ensure current and future obligations are met with respect to Public Reporting of quality outcomes.


  • Masters Degree in Health Care related field required.
  • 5 years of related experience
  • 3 years of management experience
  • Advanced interpersonal communications skills to assure a collaborative positive culture of quality and safety
  • Knowledge of various aspects of quality and process improvement through IHC, IHI, Lean Systems management and other techniques.
  • Experience in effective presentation of quality efforts to medical professionals of multiple disciplines
  • Knowledge of Clinical Practices
  • Knowledge of regulatory requirements of multiple accrediting organizations including TJC, DOH and CMS
  • Advanced analytic skills
Licensure, Certifications, and Clearances:
  • Act 34 Criminal Clearance
UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $0 to $0

Union Position: No

At UPMC, our shared goal is to create a cohesive, positive, experience for our employees, patients, health plan members, and community. If you too are driven by these values, you may be a great fit at UPMC!


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