Position Summary

This role works in an integrated function with the assigned Market Manager and the System Directors of Quality Improvement, Safety, Regulatory and Infection Control. Together they work as an integrated Quality Institute team with the leadership of the assigned market. Their combined deliverables are outlined as follows, with more specifics to this role in the following section. Ensures compliance with standard processes for managing all aspects of Quality Institute functions of safety, quality improvement and regulatory. Ensuring standards are met for each process, including timelines for completion and standards of process in managing each area within the hospital. Works to ensure metrics meet aspirational target goals and compliance across the organization

This position will float between UH Conneaut and Geneva Medical Centers.

Essential Functions

• Clinical Process Improvement and Change Management - In collaboration with local, market and UH leadership, creates multiple program methodologies for improving clinical performance and implementing needed changes to improve care and outcomes.
• Quality & Performance Improvement - Partners with clinical leadership to assess patient care for gaps to design and implement evidenced based practices and work flow.
• Clinical Risk Management - Directs clinical leadership with support from Legal Department and Risk Management Council to proactively identify and remediate clinical risks, and implement risk reduction strategies. Investigates patient harm events and sentinel events; assists clinical leadership to plan corrective action(s).
• Patient Safety - Collaborates with system and local clinical leadership in directing a patient safety program and design processes to improve safety of care consistent with best practices and accreditation standards.
• Accreditation - Leads local initiatives in conjunction with system leadership to achieve full compliance with all regulatory standards. Anticipates regulatory changes and is recognized as a leader in response to accreditation readiness.
• Infection Control and Prevention - Leads the program to prevent and control the spread of infections and develops performance improvement activities to reduce the incidence of hospital acquired infections.
• Quality data collection and reporting - Creates and maintains a method of the accurate reporting quality data to internal and external stakeholders in conjunction with system direction. Oversees local data collection and reporting to assure adherence with the UH system and entity-specific Quality & Safety Plan, Performance Improvement Plan, and Work Plan. Applies data reporting principles and analytic methodology to work flow to ensure optimal data capture.

Required For All Jobs

• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during orientation.
• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.