Job Description

Overview

Under limited supervision, plans, coordinates, leads, and monitors quality improvement initiatives within clinical service departments and across the UMMC Downtown campus (organization). Communicates with organizational leadership to drive change toward high reliability and Zero Harm. Ensures awareness of and implements the UMMC Quality Assurance/Performance Improvement (QAPI) program and the Annual Operating Plan (AOP) goals. Provides leadership and direction to multi-disciplinary teams to collaboratively accomplish quality improvement strategies at UMMC. Accountable for overall quality of care and compliance with quality requirements as outlined by CMS, Joint Commission, and disease-specific certifications. Collects and analyzes data, conducts presentations, provides consultation, and staffs and leads service-specific and organization-wide committees. Promotes UMMC on its journey to become a High Reliability Organization (HRO).

The position encompasses various roles (e.g., subject matter expert, coordinator, educator, project manager, data analyst, facilitator) and requires effective interpersonal, management, and leadership skills. A working knowledge of clinical workflows and strong leadership skills are integral to gaining credibility and collaboration from colleagues. Duties include working with UMMC clinical service departments on quality improvement strategies to 1) enhance clinical/patient outcomes, 2) maximize financial rewards within the State of Maryland pay-for-performance programs, and 3) optimize the organizations ranking within Vizients Quality and Accountability (Q&A) dashboard. This role works with organization leadership, staff, advanced practitioners, and physicians to provide a planned, systematic, organization-wide approach to identify, measure, monitor, and evaluate quality improvement activities to foster a Zero Harm environment while promoting principles of a High Reliability Organization. This position develops and maintains interactive and collaborative relationships with key medical staff (including Chairs); collaborates with and provides structure and guidance to clinical service departments; and serves as a vital quality improvement resource to clinical teams and support staff including faculty, unit dyads, and front-line team members.

Principal Responsibilities and Tasks

The following statements describe the general nature and level of work and are not an exhaustive list of duties.

• Assist in the coordination and implementation of activities in the journey to become a high reliability organization with a focus on Zero Harm
• Collaborate with organization and Quality leadership to direct and implement the bi-campus, integrated quality improvement program, including:
• Quality Program Management
• Oversees implementation of the quality improvement program for improving organizational performance, including facilitating and leading multidisciplinary teams of physicians and senior leaders
• Develops and leads projects aligned with organizational, department, and clinical service priorities, including UMMCs QAPI program, AOP goals, Maryland pay-for-performance programs, and Vizient Q&A dashboard (projects may cross both campuses)
• Actively collects, reviews, analyzes, and monitors organizational performance data to identify trends affecting patient care or financial performance; identifies and prioritizes opportunities for quality improvement projects and evidence-based practice changes
• Leads and manages special quality improvement projects, identifying resources, personnel, and project management requirements
• Collaborates with leadership to prioritize improvement efforts
• Ensures action plans are implemented to sustain improvements before hand-off to service line leaders
• Participates in key organizational quality improvement committees, teams, and projects (may cross campuses)

• Leadership

• Collaborates with staff, senior leaders, Chairs, and Lead Quality Physicians to identify quality improvement priorities that align with QAPI and AOP goals
• Advances culture of quality improvement and Zero Harm with organizational leadership
• Facilitates clinical review and problem-solving using RCA, PDSA, Process Improvement, Lean tools
• Meets regularly with Lead Quality Physician to review data and present quality issues
• Develops and implements education for employees and medical staff on quality improvement methodologies and goals
• Provides just-in-time training to support champions, leaders, and teams
• Keeps quality improvement teams on track with timelines and expected results

• Data Management

• Supports improvement work for Maryland pay-for-performance programs and/or Vizient Q&A dashboard
• Monitors quality indicators to identify trends aligned with strategic objectives
• Maintains accuracy of dashboards (e.g., QSDR, Quality Dashboard by Service) with OHAI
• Identifies trends or patterns to improve quality and safety; may cross campuses
• Provides consultation to ancillary and clinical departments to analyze data and formulate improvement plans
• Leads regulatory compliance strategies regarding QAPI, including:
• Ensures compliance with Joint Commission PI Chapter and CMS 42 CFR 482.21
• May participate in organizational visits from accrediting bodies
• May participate in Joint Commission tracers and provide staff education on quality compliance
• May oversee actions taken in response to regulatory improvement recommendations

Qualifications

Education and Experience

• Bachelors degree in Nursing or a related health science field; Masters Degree preferred
• Current licensure in Nursing or related field required
• Three years of progressively responsible professional experience in quality improvement or equivalent
• Experience in an Academic Medical Center preferred

Skills

• Demonstrated broad knowledge of quality improvement methodology and tools
• Proven leadership ability and problem-solving skills
• Ability to facilitate quality improvement in a clinical setting
• Ability to monitor, evaluate, and motivate performance and coach staff
• Ability to manage projects with limited supervision
• Ability to develop collaborative programs across disciplines
• Knowledge of state and federal regulations and Joint Commission standards for acute care hospitals; familiarity with DHMH for licensure and conditions of participation
• Strong verbal and written communication skills with all levels of personnel
• Ability to assess safety, quality, and regulatory compliance problems and implement timely solutions
• General knowledge of PC and database management software; basic project management; strong presentation skills

Additional Information

All your information will be kept confidential according to EEO guidelines.

Compensation

• Pay Range: $40.61-$60.96
• Other Compensation (if applicable):

Review the 2025-2026 UMMS Benefits Guide

Employment type

• Full-time

Job function

• Other
• Industries: Hospitals and Health Care

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