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The Senior Director, Quality Improvement provides leadership and direction for quality improvement strategies for University of Maryland Medical Center Campuses.  Works with leadership, staff and physicians to provide a planned, systematic, organization-wide approach to identify, measure, monitor, and evaluate quality improvement activities. Ensures the development of clinical practice guidelines, standards and application of benchmarking and best practice applications to support the delivery of high-quality, evidence-based care. Establishes goals and objectives aligned with the annual operating plan, including education, training, data management, and leadership. In coordination with nursing and faculty, develops and implements operating policies and procedures; interprets and ensures compliance with UMMC policies, quality standards, regulations and codes. 

Demonstrate personal leadership in clinical effectiveness, and quality through demonstrated expertise at both setting strategic direction, designing innovative ways to improve performance, and assuring successful implementation of specific tactics to assure reliable and sustained quality outcomes in the delivery of patient care across all settings. Effectively motivates and leads departmental staff and supports the professional development of a results-oriented team. 

Responsibilities and Tasks 

• Leads, tracks, and monitors the performance of UMMC Quality Improvement Programs. 
• Utilizing high reliability organizing principles develops, implements and evaluates programs to maintain UMMC-wide quality improvement programs through effective utilization of personnel and materials 
• Ensures the provision of regular and comprehensive quality reporting to School of Medicine Clinical Departments and Patient Care Services (to include targets, trends and regulatory requirements, case type data, mechanisms for requiring action, and information flow requirements in accordance with Plan for Improving Organization Performance. 
• Provides consultation to ancillary support and clinical departments within the Medical Center to establish quality indicators, analyze quality data, conduct medical record reviews to identify trends/patterns, formulate plans for resolving issues/problems, and monitors plans for effectiveness. 
• Coordinates special quality improvement projects and studies. Identifies resources needed, persons to be involved and the logistics of accomplishing the project. 
• Annual review and implementation of the UMMC Plan for Improving Organizational Performance. 
• In collaboration with Medical Affairs, Regulatory, and Patient Safety, ensures compliance with external regulators and accrediting agencies) i.e. Office of Healthcare Quality, Joint Commission) 
• Facilitates the development of Clinical Practice Guidelines (CPG) and establishes metrics for tracking and monitoring CPG adherence and impact. 
• Oversees Quality Improvement initiatives focused on providing evidence-based healthcare services to improve care equity, diversity, and inclusion. 
• Oversees functional teams responsible for the improvement in performance program tactics including but not limited to readmissions, timely follow-up after hospital discharge, potentially avoidable utilization, and any target listed in the annual quality improvement plan (ex: MHACs).

Education and Experience 

• Healthcare administrator or registered nurse, advanced practice provider, or other allied health-related professional with a current license to practice in Maryland. 
• Master's Degree in Health Care Administration, Business, or related field preferred 
• Seven or more progressively responsible years of experience performing safety and quality improvement is required, including experience in developing new and innovative quality initiatives with a special focus on partnering with physicians. 
• Three years of leadership experience in healthcare quality in an acute care facility is required. Experience in an Academic Medical Center is preferred. 
• Certified Professional in Healthcare Quality (CPHQ) preferred. 

Knowledge, Skills and Abilities 

• Demonstrated effectiveness in managing, and directing departmental operations and management/supervisory personnel, evaluating, training and motivating performance. 
• Ability to accomplish results through others. Demonstrated ability to delegate effectively and to establish clear guidelines for accountability. Ability to build consensus and provide strong leadership in a team environment, with the highest professional and personal integrity. 
• Knowledge of current reimbursement and clinical issues academic medical centers who serve as safety net providers and the safety net provider mission is preferable. 
• Comprehensive knowledge of federal, state and local requirements of regulatory and accreditation agencies is required. 
• Proficient knowledge of quality improvement measurement, analysis and improvement strategies is required. 
• Highly effective communication skills are necessary to work with Medical Staff, Board of Directors, Administration/Senior Management, hospital personnel, the media, and the community