Director, Quality Safety and Regulatory

Exemption Status:

Schedule Details:

Scheduled Hours:

Shift:

Hours:

Cost Center:

This position may have a signing bonus available a member of the Recruitment Team will confirm eligibility during the interview process.

At UMass Memorial Health, everyone is a caregiver - regardless of their title or responsibilities. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve. We are more than 16,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other. And everyone, in their own unique way, plays an important part, every day.

I. Position Summary:

Reporting to the, AVP Quality, Safety and Regulatory the Director works in collaboration with other members of the leadership team for the Center for Quality and Safety (CQS), including the Departmental Physician Quality Officers, in the implementation of key quality, regulatory and safety initiatives for UMass Memorial Medical Center (UMMMC) and the UMass Memorial Medical Group (UMMMG). The Director will oversee members of the Quality, Patient Safety, and Regulatory (QPSR) team within CQS. The Director should have a strong background in quality and safety principles, performance improvement, hospital regulatory and accreditation requirements as well as demonstrated leadership skills.

II. Major Responsibilities:

• Provides leadership and oversight of improvement work by members of the Center for Quality and Safety as it pertains to improving quality of care, enhancing patient safety and ongoing regulatory compliance.
• Plan and initiate improvement activities with key stakeholders to drive improvement with the Quality, Patient Safety, and Regulatory staff and workforce members.
• Evaluates and improves the patient safety & quality program based on internal needs and external requirements and standards.
• Serves as the liaison on issues related to Joint Commission and Department of Public Health, including a leadership role during on-site triennial and for cause surveys.
• Serves as an advisor for service specific certifications or surveys. Collaborates with key stakeholders external to CQS including, but not limited to, Nursing/Patient Care Services, Pharmacy, Human Resources, Information Systems, Communications, Facilities, Informatics, Lab, and Patient Advocacy.
• Utilizes data from the Safety Intelligence system, Root Cause Analyses (RCA) and other internal and external data bases to understand potential safety vulnerabilities and leads efforts to create and sustain innovative systems that eliminate patient harm.
• Facilitate the use of Lean or other proven quality improvement methodologies and tools with the QPSR and other teams to improve and standardize workflows throughout the Medical Center.
• Supports the assessment of the Culture of Safety and works with teams to implement defined improvements based on organizational data.
• Collaborates with other key stakeholders, to build efficient structures to ensure changes in relevant CMS, DPH and Joint Commission are communicated and accessible to all caregivers as appropriate.
• Works with Risk Management, insurance providers and patient advocates when needed on investigations related to quality, patient safety and regulatory issues.

III. Position Qualifications:

License/Certification/Education:

Required:

Master's degree in nursing, hospital or medical administration, healthcare, business administration, or equivalent

Preferred:

Clinical degree such as RN, PharmD, RD, RT, PT, OT, SW, or similar. Certified Professional in Healthcare Quality, Certified Professional in Patient Safety, or formal training in Process Improvement (e.g. Lean) preferred and commitment to obtaining certification if applicant currently does not have it.

Experience/Skill:

Required:

• Minimum 3 years of experience in a leadership role within healthcare or hospital administration.
• Minimum of 7 years of experience in quality, safety, regulatory, or applicable fields.
• In depth knowledge of patient safety science, publicly reported quality measures, operations analysis, quality management, and performance improvement methods.
• Must have demonstrated leadership, change agent and project management skills.
• Excellent verbal and written communication skills.
• Ability to effectively utilize a variety of computerized software applications such as spreadsheet, word processing, relational database, and graphics software packages.

Preferred:

Experience operating in an academic medical center environment.

Requires excellent communication skills and experience in leading teams

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

We're striving to make respect a part of everything we do at UMass Memorial Health - for our patients, our community and each other. Our six Standards of Respect are: Acknowledge, Listen, Communicate, Be Responsive, Be a Team Player and Be Kind. If you share these Standards of Respect, we hope you will join our team and help us make respect our standard for everyone, every day.

As an equal opportunity and affirmative action employer, UMass Memorial Health recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives and backgrounds. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, gender identity and expression, protected veteran status or other status protected by law.

If you are unable to submit an application because of incompatible assistive technology or a disability, please contact us at talentacquisition@umassmemorial.org. We will make every effort to respond to your request for disability assistance as soon as possible.