Sr. Quality and Safety Specialist

As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive.

Job Location (Full Address):

601 Elmwood Ave, Rochester, New York, United States of America, 14642

Opening:

Worker Subtype:

Regular

Time Type:

Full time

Scheduled Weekly Hours:

40

Department:

500021 Clin Practice Evaluation Ofc

Work Shift:

UR - Day (United States of America)

Range:

UR URG 112

Compensation Range:

$70,197.00 - $105,295.00

The referenced pay range represents the minimum and maximum compensation for this job. Individual annual salaries/hourly rates will be set within the job's compensation range, and will be determined by considering factors including, but not limited to, market data, education, experience, qualifications, expertise of the individual, and internal equity considerations.

Responsibilities:

GENERAL PURPOSE:
Provides oversight of the hospital’s quality assessment/performance improvement program for assigned areas of responsibility. Coordinates and processes hospital grievances. Develops and implements programs, policies, and practices to ensure compliance with organizational and governmental standards and makes recommendations for updates. Documents regulations. Develops and delivers training programs to enhance awareness and adherence to safety and quality standards. Maintains communications with leadership regarding quality and safety activities. Coordinates and conducts the assessment of internal controls to ensure compliance as required by regulatory commissions/authorities. Administers programs and adheres to processes to manage complaint cases brought to regulatory authorities and develops and maintains process improvements to avoid future complaints.

ESSENTIAL FUNCTIONS

Coordinates and supports quality management initiatives

• Ensures compliance with the SMH Quality Assessment/Performance Improvement plan (QA/PI) and that the hospital’s plan is in compliance with regulation and accreditation requirements.
• Uses information from the event reporting system, clinical services, the findings of quality assurance studies, quality teams and the clinical and financial databases to detect trends, patterns of performance, or potential quality or safety concerns.  These data are reported to the Chief Executive Officer, Medical Director, Medical Staff committees and to the JMQC as well as to the respective departments.

Coordinates assigned councils, programs, services, and service lines in respective quality areas

• Oversees and reviews QAPI plans and ensures departments are meeting regulatory requirements for QAPI activities.
• Provides education, coordination and support to department QA Liaisons for the QA activities performed in medical staff departments.
• Tracks the status of identified problems and opportunities for improvement to assure resolution or improvement, including tracking of compliance with action plans.
• Provides support to assigned departments for the event reporting system to ensure events are input and event data analyzed by creating reports that departments can use to track and trend quality and safety concerns.

Coordinates Patient Grievances

• Ensures that patient quality grievances are coordinated and completed in accordance with CMS regulations, ACA 1557 Regulations and Hospital policy.
• Works cooperatively with the Patient and Family Relations Department to determine if patient complaints require follow-up according to the grievance process.
• Communicates directly with patients and families to manage identified grievance issues and follow-up during the grievance process.  Coordinates review of quality grievance issues with involved Hospital departments and summarizes responses in writing for patients and families.
• Inputs grievance related information into RL Solutions and other databases for tracking and trending of quality-of-care issues. Develops reports and presentations to communicate and share quality data trends.
• Uses in-depth knowledge of related regulatory rules and interpretive guidance to inform decisions.

Participates in patient safety and quality improvement meetings including, but not limited to:

• Medical Error and Risk Management-review of serious adverse events
• Patient Safety and Risk Management – review of Root Cause Analyses