Mgr, Quality & Safety,Dept (L)

Job Location: Remote Work - New York, Albany, New York, United States of America

Full-time, scheduled weekly hours: 40

Compensation Range: $77,600.00 - $116,400.00

Responsibilities

• Collaborates with the institute's senior leadership team on strategic initiatives and performance improvement goals.
• Ensures Orthopaedic and Musculoskeletal Service Line objectives are aligned across the service line, and the institute is achieving quality objectives.
• Utilizes, integrates, and interprets data (e.g. PROMIS, NSQIP, Vizient, etc.) to assist the Musculoskeletal Service Line in its improvement efforts, promotes optimal patient outcomes, optimizes reputation, increases quality of care, and reduces reputational risk while reducing disparities in care.
• Continuously evaluates work process and design; understands the role in ensuring quality/performance improvement, productivity, and service delivery to meet the institute's stakeholder needs.
• Participates in and coordinates quality reviews to both drive safety and outcomes, and for regulatory compliance.
• Collaborates with system-wide (SMH, HH, FF TH, FLH, NMH, JMH, SJM) quality and safety leaders to identify and fulfill data requirements. Develops and maintains system-level dashboards by integrating data from multiple sources, including CMS and Vizient, ensuring comprehensive and actionable insights.
• Partners with data programmers and IT teams to design and sustain accurate data pulls, verifying the appropriateness of variables and calculations used. Establishes and promotes the use of standardized "Blue-Ribbon" variables and measures to ensure consistency and reliability in report development.
• Actively engages hospital and system leaders in data review processes during relevant meetings to drive informed decision-making.
• Coordinates the development of ad hoc reports by working closely with clinical and operational leaders to understand specific data needs and address any limitations stemming from data collection methods or workflow constraints. Ensures that report results are complete, accurate, and easily interpretable. Designs clear and effective visualizations to facilitate accurate data interpretation and actionable insights.
• Acts as liaison between department faculty and OCMC and Risk Management.
• Manages registry measure validation and quality testing, collaborating with IT, Registry, and Quality staff to implement validation requirements.
• Provides education to providers, staff, and trainees in quality science and process improvement techniques, and encourages stakeholder engagement.
• Participates in and facilitates the Quality Coordinating Council, Perioperative Quality Council, Orthopaedics Quality Committee, and any associated divisional quality meetings, programs, and initiatives.

Patient Safety

• Actively contributes to and works toward institute-wide improvement in meeting strategic measures, patient safety, and service excellence goals.
• Deploys established methodology (e.g. RCA, FMEA, lean, gap analysis) to analyze and improve safety and optimize clinical workflows aligning operational efficiency and quality. Monitors similar analyses across the regional service line.
• Works collaboratively with Patient Family services on grievances that are received from an Orthopaedic patient who received care while either in the clinic and/or under care in the OR.

Patient Experience

• Leads efforts to drive meaningful improvements in patient experience by collaborating with leadership to identify, prioritize, and implement strategic initiatives.
• Provides oversight and direction for the Patient Experience program, including efforts to enhance patient satisfaction, address complaints, and resolve grievances effectively.
• Conducts comprehensive analysis of internal and external customer satisfaction metrics and performance analytics to monitor trends, identify areas for improvement, and develop actionable plans to enhance outcomes.
• Supports URMC hospital programs by designing and analyzing dashboards, generating detailed reports, and recommending strategies to improve reporting accuracy and quality performance metrics.
• Oversees responses to third-party payer inquiries related to patient concerns, ensuring timely and effective resolution.
• Partners with the URMC Patient Experience Office to develop and facilitate the Patient and Family Advisory Council, fostering collaboration and engagement to improve patient-centered care initiatives.
• Participates in inpatient unit quality rounds.

Compliance

• Leads efforts to monitor, evaluate, and enhance clinical protocols, practices, and management guidelines. Conducts audits, case reviews, and trend analyses to ensure compliance with quality indicators and drive continuous improvement.
• Develops and implements procedures to maintain required certifications and verification standards, ensuring adherence to regulatory criteria and national benchmarks.
• Oversees the design and maintenance of specialty registries, ensuring data integrity and accuracy for performance improvement, reporting, and research purposes.
• Facilitates communication and cooperation among healthcare disciplines, external stakeholders, and regulatory bodies. Builds positive relationships with physicians, referring hospitals, and community partners.
• Coordinates and delivers training programs for healthcare providers, including onboarding, specialty service meetings, and educational courses to support certification and improve care standards.
• Assists in developing and maintaining business plans, including benchmarking analysis, budget objectives, and long-term strategic goals to support program growth and sustainability.
• Assists department leadership in the design, administration, and monitoring of yearly MCIC initiatives.

Requirements

• Bachelor of Science in Nursing or equivalent graduate training or experience in a specialty suited to the assignment required.
• 8 years relevant work experience including substantial work at a managerial level, preferably in a healthcare setting; equivalent combination of education and experience required.
• Experience with quality assurance and quality improvement processes is required.
• Minimum of 5 years of clinical experience or equivalent combination of education and experience required.
• Experience with Joint Commission, CMS and NYSDOH continuous survey readiness preferred.
• Experience with quality initiatives in clinical settings required.
• Minimum of 5 years of experience in a quality management role preferred.

Skills

• LEAN preferred.

Qualifications

• Certified Professional in Healthcare Quality (CPHQ), or Certified Professional In-Patient Safety (CPPS) desired.