**Description** Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines. Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work? Summary: + Reporting to the Pennsylvania Hospital (PAH) Chief Medical Officer (CMO), The PAH Director of Quality and Patient Safetyprovides leadership and oversight of the Department of Clinical Effectiveness and Quality Improvement (CEQI), withresponsibility for PAH's activities in Quality Improvement, Patient Safety, Outcomes Management, and Reporting, in support ofPenn Medicine's strategic goals as expressed in the Blueprint for Quality and Patient Safety. This position works collaborativelywith the Patient Safety Officer, the Director of Regulatory Affairs and Accreditation, the Director of Infection Control, the PAHExecutive Leadership team and PAH Medical Staff Leadership, to lead the organization to outstanding performance on keymetrics in quality and patient safety. The position manages the daily operations of the CEQI Department including policy andprocedure development, staffing, scheduling, payroll, and ensuring efficient and thorough completion of the key activities ofthe department. This position has visibility across the organization and routinely interacts with all levels of staff andmanagement. This position works with the UPHS Chief Medical Officer and other entity Quality Directors to provide input onstrategy, participate in decision making related to key quality issues, and assure dissemination and spread of successful qualityimprovement projects. In addition, the position works with the following corporate departments: Risk Management/ Legal,Quality and Patient Safety, the Penn Medicine Academy, Health Information Management (HIM), the Office of Medical Affairs(OMA), the Office of Patient Affairs (OPA), the Penn Medicine Privacy Office and the Office of General Counsel. Responsibilities: + Quality and Process Improvement 1. Provide leadership and direction to continuous process improvement activities at the entity + support strategic development and maintenance of processes necessary to integrate clinical performance improvement activities at the entity + follow the Performance Improvement Plan. a. Provide specialized resources to assist in quality improvement activities, including: i.Lead change management ii.Lead using process improvement methodology (Lean, Six Sigma, PDSA, etc.) b. Support educational programs to transfer skills in quality and process improvement + liaison to Penn Medicine Academy to offer consultation in Performance Improvement In Action program and curriculum c. Work collaboratively to embed excellence in quality improvement + utilizing the Blueprint for Quality and Patient Safety to guide improvement d. Support the UPHS Clinical Effectiveness and Quality Improvement (CEQI) initiatives through the entity CEQI Committee and UPHS CEQI Committee. 2. In collaboration with Clinical Department leaders , including respective PAH Executive Leadership Team members: a. Facilitate clinical performance improvement efforts of the Penn Medicine system-wide collaboratives. b.Support the work of the Clinical Effectiveness Teams, to insure optimal functioning of the teams to meet the organization’s needs c.Support data management and quality improvement efforts related to: i.Value-based Purchasing and other publicly reported metrics iii.Payor-specific Pay for Performance contracts. iv.Provider Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE). 3. Coordinate efforts to communicate results of analyses impacting quality, efficient and safe clinical care with leadership team. 4. Lead participation of the hospital in regional, state and national quality collaborative, in conjunction with UPHS (i.e. Vizient, HAP) 5. Support the development and presentation of quality/safety research in local, regional and national forums. + Clinical Quality Data Management 1. Oversee and/or support, as appropriate, the processes of data abstraction and reporting related to programs and specialty registries that include, but are not limited to the following: Vizient, PA Healthcare Cost Containment Council, CMS, the Joint Commission, the Pennsylvania Department of Health, disease-specific registries, Get With the Guidelines, NSQIP, etc. 2. Monitor publicly reported data, identify opportunities for quality improvement. 3. Ensure the accuracy and integrity of all entity data produced by PennDNA for Inpatient and Outpatient Analytics. 4. Represent entity through UPHS Committees, Alliances and Collaboratives with engagement related to the development and utilization of clinical quality data reporting, quality improvement and patient safety. 5. Coordinate data management efforts in support of strategic plans and policies for improved quality throughout the entity. + Patient Safety 1. Oversee the implementation, assessment, and continuous improvement of the hospital’s patient safety plan, to eliminate medical errors through timely reporting, early identification of systems defects and implementation of solutions that promote patient safety. 2. Insure prompt, reliable, and thorough review of reported patient safety events. 3. Coordinate and monitor the completion of all root cause and apparent cause analyses. 4. Oversee and monitor patient safety event management operations via the Penn Medicine event reporting and management system, providing standing and ad hoc reports, as necessary, to entity leaders. 5. In cooperation with Risk Management, Regulatory Affairs, and Infection Control, oversee the written disclosure to patients/families for events under Act 13 and Act52. 6. Lead and direct others using the principles of a high reliability organization (HRO). + Critical Functions 1. Oversee and direct the operations with the Clinical Effectiveness and Quality Improvement department. a. Develop budgets, policies and goals. b. Perform and review employee performance evaluations. c. Work with Human Resources to develop leadership competencies and succession planning in the department. Credentials: Education or Equivalent Experience: + Master of Arts or Science (Required) + Education Specialization:Nursing, Business, or Health PolicyEquivalent Experience:•5+ years Leadership experience in healthcare•5+ years Experience in quality management with technical knowledge of the administrative, operational and clinical healthcare functions including: quality and process improvement, regulatory/compliance, clinical quality data management, and patient safety•Experience having coordinated, prepared and participated in state, Joint Commission and/or CMS survey within the past 3 years preferred•Six Sigma, Lean and/or IHI Improvement training (PDSA) preferred. We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives. Live Your Life's Work We are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law. REQNUMBER: 284024