Details
Posted: 05-Jun-25
Location: Baltimore, Maryland
Categories:
Operations
Internal Number: REF39285V
Job Description
Responsible for planning, coordinating, monitoring, and leading quality improvement initiatives within Perioperative and Procedural Services across both UMMC campuses, including data analysis, project management, and team facilitation to enhance patient outcomes, optimize financial performance, and improve hospital rankings. Partner with leadership and interdisciplinary teams to drive high reliability, patient safety, and regulatory compliance while fostering a culture of continuous improvement. Ensure continuous implementation of UMMC's Quality Assurance/Performance Improvement program, promote a Just Culture, and integrate best practices to sustain improvements in perioperative quality and safety. Work is performed under limited supervision. Direct report to the Vice President, Perioperative and Procedural Services.
Primary Responsibilities
The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job responsibilities performed.
* Develop and oversee the perioperative quality improvement program, aligning efforts with hospital-wide initiatives, regulatory requirements, and annual operating plan goals.
* Lead multidisciplinary teams across both campuses to execute quality improvement projects that enhance clinical outcomes, efficiency, and patient safety.
* Collect, review, analyze, and monitor performance data to identify trends impacting patient care and financial performance.
* Collaborate with hospital and departmental leadership to prioritize quality improvement efforts, ensuring sustainability through effective action plans.
* Ensure ongoing compliance with quality and safety standards set by CMS, Joint Commission, and disease-specific certifications.
* Develop and implement strategies to reduce Potentially Preventable Complications (PPCs), Patient Safety Indicators (PSIs), surgical site infections, and hospital-acquired pressure injuries (HAPIs).
JOB DESCRIPTION
* Work with senior leadership, clinical department heads, and Lead Quality Physicians to establish and implement quality improvement priorities aligned with UMMC's strategic plan.
* Facilitate root cause analyses, Plan-Do-Check-Act (PDCA) cycles, and other process improvement methodologies to drive sustainable changes.
* Meet regularly with perioperative leadership and service line leads to review performance data, identify quality gaps, and develop targeted improvement strategies.
* Provide education and just-in-time training on quality improvement methodologies, high reliability principles, and performance improvement tools.
* Coach and mentor clinical leaders, staff, and physicians on quality and safety initiatives, fostering a culture of accountability and excellence.
* Actively participate in key hospital-wide quality committees, collaboratives, and strategic planning initiatives.
* Support the development of posters, presentations, and publications highlighting UMMC's quality improvement efforts at internal and external conferences.
* Lead initiatives to improve key quality metrics within Maryland's pay-for-performance programs and the Vizient Q&A dashboard.
* Monitor and ensure the accuracy of perioperative quality dashboards, providing actionable insights for leadership and clinical teams.
* Collaborate with Performance Innovation and other stakeholders to leverage data for continuous quality monitoring and improvement.
* Identify trends and opportunities for improvement in patient safety, efficiency, and compliance with accreditation and licensing standards.
* Support regulatory readiness efforts, including preparation for Joint Commission, CMS, and state health department surveys.
* Participate in hospital-wide tracers and provide real-time staff education on regulatory compliance and hospital policy requirements.
* Perform other duties as assigned
Company Description
When we say "our community" we mean it.
UMMC Midtown Campus, one of two campuses of the University of Maryland Medical Center, has had a long history of working to keep our community healthy and has grown to become a trusted teaching hospital for medical and surgical care in Baltimore City.
Located in Baltimore's cultural center near the historic Mount Vernon neighborhood, UMMC Midtown Campus is a 180-bed, community teaching hospital with a focus on helping people manage chronic diseases, including diabetes, hypertension, pulmonary conditions, and infectious diseases.
Qualifications
* Master's degree in Nursing, or related field, or the equivalent combination of education, training, and experience.
* Five years of progressively responsible professional experience in quality improvement, patient safety, or similar in a healthcare setting.
* Proven track record of leading process improvement initiatives and implementing data-driven solutions in a healthcare environment.
* Current licensure in Nursing or related field (e.g., physical therapy).
Education & Experience - Preferred
* Experience in an Academic Medical Center.
* Experience in perioperative and procedural services.
Knowledge, Skills, & Abilities
* Advanced knowledge of quality improvement methodologies, data analysis, and performance improvement strategies.
* Working knowledge of applicable federal, state, and local laws, rules, and regulations (e.g., The Joint Commission, etc.).
* Working knowledge of Department of Mental Health & Mental Hygiene for state licensure and medical conditions for participation
* Strong leadership skills with a track record of driving organizational change and fostering a culture of safety.
* Proficiency in regulatory compliance, including Joint Commission, CMS, and state hospital licensing requirements.
* Strong project management capabilities with the ability to oversee multiple initiatives and track performance against defined goals.
* Proficiency in statistical analysis, database management, and dashboard reporting to support data-driven decision-making.
* Ability to educate and train diverse stakeholders on quality improvement principles and best practices.
* Advanced skill developing and maintaining collaborative working relationships with all levels of leadership, physicians, and frontline staff.
* Advanced analytical, critical thinking, planning, organizational, and problem-solving skills.
* Advanced skill presenting findings, conclusions, alternatives and information clearly and concisely at all levels within the organization.
* Exhibit high self-motivation and ability to work and plan independently as well as in a team environment.
* Ability to analyze, compare, contrast, and validate work with keen attention to detail.
* Advanced skill in the use of Microsoft Office Suite (e.g., Excel, Word, PowerPoint).
* Advanced verbal, written and interpersonal communication skills.
