Description

Purpose:
Directs the functions of the Quality Department to ensure high value, high quality, safe, reliable care and drive continuous process improvement. Accountable for all matters pertaining to the quality, safety, regulatory, and infection control programs at assigned facilities.


Responsibilities:

• Act as liaison with local and state health departments and other healthcare facilities by reporting notifiable diseases and investigating communicable conditions.
• Investigate clusters and outbreaks for sources of infection, educate healthcare personnel regarding short and long term control measures and assist in evaluation of the effectiveness of such controls.
• Identify trends in hospital infections through review and interpretation of surveillance data to develop risk reduction strategies and implement process improvement initiatives. Provide analysis and interpretation of data collected during surveillance activities. Develop reports to communicate trend data and analysis.
• Facilitate operational responsibilities of infection prevention and control in mandatory reporting as outlined in Pennsylvania State law( ACT 52.) including identification of infections, reporting through the National Healthcare Safety Network (NHSN), contacting physicians of patients with infections to inform them of notification process and fielding questions from patients with infections reported under ACT 52.
• Document infection data in an electronic surveillance sytem as required by PA DOH ACT 52.
• Serve on the Infection Prevention and Control Committee and represent Hospital Epidemiology in hospital committees requiring Infection Prevention and Control input.
• Develops and implements the individual quality plan and ensures that this plan integrates and supports the strategic plan, working collaboratively with the Quality Department.
• Serves as a resource and support for healthcare acquired conditions, readmissions and patient safety indicators. Analyzes the events to identify opportunities for improvement. Organizes, reports and maintains the peer review process.
• Accountable for the budget of the Quality Department; has direct responsibility for producing revenue and/or managing costs.
• Drives performance improvement measures and collaborates with departments to develop and implement performance improvement projects. Develops and implements creative solutions to address events.
• Ensures that regulatory guidelines are met regarding Joint Commission standards, Department of Health regulations and CMS Conditions of Participation. Plans and coordinates survey activities, audits and improvement activities.
• Serve as Privacy and Compliance Officer at assigned facilities.
• Coordinate and oversee the Medical Peer Review process at assigned facilities
• Coordinates patient experience reporting by analyzing data and driving implementation of improvement plans.
• Chairs entity level Environment of Care (EOC) Committee, co-chairs system level EOC Committee and is responsible for continued survey readiness related to EOC.
• Supervises and maintains all quality reporting related to reimbursement and quality ratings.

Qualifications

• Master's Degree required
• 7-10 years Healthcare Related Experience required, with 5-7 years Supervisor Experience preferred
• Certification in related area of expertise preferred.
• Quality management experience preferred.

Licensure, Certifications, and Clearances:
Registered Nurse licensure in the Commonwealth of Pennsylvania Required
 

• Registered Nurse (RN)
• Act 33 with renewal
• Act 34 with renewal
• Act 73 FBI Clearance with renewal


• UPMC is an Equal Opportunity Employer/Disability/Veteran

Total Rewards

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Our Values

At UPMC, we’re driven by shared values that guide our work and keep us accountable to one another. Our Values of Quality & Safety, Dignity & Respect, Caring & Listening, Responsibility & Integrity, Excellence & Innovation play a vital role in creating a cohesive, positive experience for our employees, patients, health plan members, and community. Ready to join us? Apply today.