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Job Description

Job Title: Director, Quality, Safety & Exp
Job ID: 910663414
Status: Casual
Regular/Temporary: Limited
Shift: Day Job
Facility: UPMC Chautauqua WCA
Department: Nursing Administration
Location: 207 Foote Avenue, Jamestown NY 14702


Provides administrative leadership and overall direction to the Quality, Patient Safety, Regulatory, Infection Control, and the Patient Experience functions.

  • 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.
  • Demonstrate an interactive leadership style that influences thinking and reshapes the quality environment.
  • 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.
  • Conduct an analysis of clinical variance trends and recommendations for clinical practice changes. Investigate and implement creative methods to improve process.
  • Provides administrative leadership and overall direction to the Quality, Patient Safety, Regulatory, Infection Control, and the Patient Experience functions.
  • Effectively participate and engage in activities to support and achieve organizational strategic goals including an analysis of quality programs and patient care outcomes.
  • Serves as the local leadership contact, in conjunction with Patient Safety staff, for the UPMC Risk Management department and collaborates as such.
  • Serves as Facility Contact for PHC4 and PHCQA.
  • 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.
  • Develop, implement, or utilize appropriate existing system data management capability that supports clinical program initiatives, decision support and regulatory compliance.
  • Provide leadership and preparation for Regulatory Compliance including DOH Licensure and Joint Commission Accreditation Surveys
  • 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.
  • Recommend changes to policies and procedures to senior leadership. Provide oversight of Policy and Procedure Committee and the revisions and improvements to the process.
  • Coach and advise professional staff in the formulation of their development plan.
  • Demonstrate a collaborative leadership role in the External Regulatory Survey process, to ensure compliance and continual readiness for accreditation and licensure surveys.
  • 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.
  • Demonstrate initiative to address complex, high-risk problems and translate them into opportunities and challenges with all levels of management.
  • Ensure budgetary standards/expectations are met by monitoring and maintaining expenses and man-hour utilization.
  • Provide input into CQSI data analytics development and reports.
  • Provide administrative oversight for Infection Control including surveillance, data collection, education, and collaboration to reduce HAI's.
  • Complete performance reviews to maintain compliance.
  • Responsible for ensuring implementation of a Patient Experience /Relations Program.
  • 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.
  • Make decisions and evaluate outcomes with adequate knowledge, information and consideration of physician stakeholders and members of the all departments.
  • Serve as the senior internal consulting resource for clinical measurement, analysis and reporting.
  • Implement programs and activities, which support the organization's quality goals. Provide oversight for all appropriate UPMC pay for performance programs.
  • Demonstrate responsiveness to the changing priorities and targets in the field of quality and patient safety, and patient experience.
  • Works collaboratively with CQSI to ensure current and future obligations are met with respect to Public Reporting of quality outcomes.


Masters Degree required 7-10 years Healthcare Related Experience required, with 5-7 years Supervisor Experience preferred. Certification in related area of expertise preferred. 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 Excellent interpersonal skills and demonstrated Leadership qualities knowledge of Clinical Practices Knowledge of regulatory requirements of multiple accrediting organizations including TJC, DOH and CMS Advanced analytic skills Ability to effective and succinctly communicate verbally and in writing to all levels of the organizations.

Licensure, Certifications, and Clearances:
CPHQ (Certified Professional in Healthcare Quality) preferred

UPMC is an Equal Opportunity Employer/Disability/Veteran

Salary Range: $0 / hour

Union Position: No

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