Location: York,PA, USA
**Purpose:**
Directs the functions of the Quality Department to ensure high value, safety and quality of care and to drive continuous process improvement. Accountable for all matters pertaining to the quality program at assigned facility.
**Responsibilities:**
+ 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.
+ Develops and implements the individual quality plan and ensures that this plan integrates and supports the strategic plan, working collaboratively with the Quality Department.
+ Drives performance improvement measures and collaborates with departments to develop and implement performance improvement projects. Develops and implements creative solutions to address events.
+ Supervises and maintains all quality reporting related to reimbursement and quality ratings.
+ Serves as the Patient Safety Officer. Maintains and cultivates a robust culture of safety and develops and conducts safety related activities.
+ 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.
+ Chairs entity level Environment of Care (EOC) Committee, co-chairs system level EOC Committee and is responsible for continued survey readiness related to EOC.
+ Develops and maintains the Patient Safety Plan. Analyzes event reports for patterns and trends to drive change and improvement in the patient safety program.
+ Coordinates patient experience reporting by analyzing data and driving implementation of improvement plans.
+ Accountable for the budget of the Quality Department; has direct responsibility for producing revenue and/or managing costs.
+ 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
**UPMC is an Equal Opportunity Employer/Disability/Veteran**