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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 facilities, specifically within Wellsboro and Cole.

Responsibilities:

• Supervises and maintains all quality reporting related to reimbursement and quality ratings.

• Chairs entity-level Environment of Care (EOC) Committee, co-chairs system-level EOC Committee and is responsible for continued survey readiness related to EOC.

• Regulatory/Compliance/Peer Review. 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.

• Serve as hospital lead for stroke care. Responsible for provision of quality care for patients experiencing a stroke in collaboration with the Stroke Medical Director and the Stroke Coordinator.

• Performance Improvement: Ensure that the Quality Assurance and Performance (QAPI) plan is implemented, and outcomes are reviewed and reported to Quality Boards as outlined in the plan. Review and analyze outcomes including healthcare-acquired conditions, readmissions, and patient safety indicators. Analyze the events to identify opportunities for improvement and collaborates with departments to develop and implement performance improvement projects. Analyze and report the impacts of outcomes on CMS Star Ratings and Pay for Performance Programs. Ensure that all mandatory data required for Critical Access Hospitals is submitted such as PHC4 data, electronic quality measures (eCQMs), and MBQIP measures. Ensure that Patient Safety standards are met per Leap Frog criteria. Collaborate with the UPMC North Central Pa. Region Director of Performance Improvement and Stroke Coordinator to analyze and improve stroke and sepsis care processes and outcomes. 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.

• Infection Control: 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 system 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.

• Patient Safety Officer: Act as Patient Safety Officer (PSO) and is responsible to coordinate the Patient Safety Program. Carry out specific aspects of the program, as defined in the hospital-specific Patient Safety Plan. Fulfills the PSO role in the Patient Safety Triad.

• Master's Degree required

• 7-10 years Healthcare Related Experience required,

• 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

• Act 34

UPMC is an Equal Opportunity Employer/Disability/Veteran