Purpose:
The Director provides administrative leadership and overall direction to the Quality, Patient Safety, Regulatory (Department of Health/The Joint Commission) and Infection Prevention functions across UPMC Altoona with some oversite over UPMC Bedford. The Director will collaborate closely with nursing and medical leadership to align clinical and operational practices to drive improvement of patient outcomes. The Director will participate in joint decision-making processes to enhance patient care and foster a collaborative environment through shared accountability between nursing and medical staff.

Responsibilities:

Provides administrative leadership and overall direction to the Quality, Patient Safety, Regulatory and the Infection Prevention functions. Serve as the senior internal expert resource for clinical measurement and analysis across areas of responsibility. Implement and become expert at utilizing appropriate clinical data systems to support improvement initiatives, decision support, and regulatory compliance work. Provide leadership and preparation through a collaborative approach in all aspects of the Regulatory Survey process to ensure compliance and continual readiness for accreditation and licensure surveys. Serves as the local leadership contact, in conjunction with Patient Safety staff, for the UPMC Risk Management department and collaborates as such. Provide administrative oversight for Infection Control including surveillance, data collection, education, and drive improvement to reduce HAI?s. Collaborate with medical and nursing leadership to implement evidence-based practices to reduce rates and improve outcomes. Provide collaborative leadership that smooth the interface points within the complex matrix environment that includes UPMC, employed physicians, private practice, and multiple care delivery sites .Effectively participate and engage in activities to support and achieve organizational strategic goals including an analysis of quality, safety, regulatory, infection prevention, patient care, and financial outcomes. Promotes a culture of safety and works to operationalize in just culture model. Establishes and implements action plans to achieve top level performance in all areas of responsibility. Demonstrate an interactive leadership style that influences thinking and reshapes the quality, safety, and improvement culture. Provide oversight and drive the performance for all appropriate UPMC pay for performance programs. Demonstrate responsiveness to the changing priorities and goals in the field of quality, patient safety, regulatory, and infection prevention. Demonstrate initiative to drive change in complex, high-risk problems and translate them into opportunities and challenges with all levels of management, including Quality Committee of the local board. Make decisions and evaluate outcomes with adequate knowledge, information, and consideration of clinical, physician, financial stakeholders, and members of all the departments. Manage human and financial resources to meet quality and cost-effectiveness standards. Prepare annual budgets based on patient, program, staff, and physician needs. Monitor expenses and man-hour utilization to meet budgetary standards. Complete timely performance reviews to ensure compliance and merit targets. Coach staff on development plans to foster retention. Collaborate with professionals across UPMC to identify and support joint educational opportunities to change clinical practice. Active participation on System Quality, Safety, Regulatory and Infection Prevention teams. Works collaboratively with the Wolff Center to ensure current and future obligations are met with respect to Public Reporting of quality outcomes. Provide input to Wolff Center leads for development and reports. Assume leadership role in the development of process improvement opportunities related to changes in clinical practice to support organizational goals. Apply innovative and creative skills to ensure that the process improvement opportunities are identified and addressed as well as meet the needs of quality and safety goals and meets regulatory guidelines. Leads robust root-cause analysis process and improvement plans. Develop relationships and integrate all team members into the team’s work. Report program findings, results, and changes at various settings and meetings. Form relationships with various settings in the continuum of care based on program issues/work. Participate in enterprise analysis of clinical variance trends and recommendations for clinical practice changes. Oversee Quality Board agenda development and meeting success.