**Purpose:** Provides administrative leadership and overall direction to the Quality, Patient Safety, Regulatory and Infection Control functions. **Responsibilities:** + Recommend changes to policies and procedures to senior leadership. Provide oversight of Policy and Procedure Committee and the revisions and improvements to the process. + Provides administrative leadership and overall direction to the Quality, Patient Safety, Regulatory and the Infection Control functions. + Develop, implement, or utilize appropriate existing system data management capability that supports clinical program initiatives, decision support and regulatory compliance. + Implement programs and activities, which support the organization's quality goals. Provide oversight for all appropriate UPMC pay for performance programs. + Complete performance reviews to maintain compliance. + Serve as the senior internal consulting resource for clinical measurement, analysis and reporting. + Make decisions and evaluate outcomes with adequate knowledge, information and consideration of physician stakeholders and members of the all departments. + Ensure budgetary standards/expectations are met by monitoring and maintaining expenses and man-hour utilization. + Serves as the local leadership contact, in conjunction with Patient Safety staff, for the UPMC Risk Management department and collaborates as such. + Provide collaborative leadership on a consistent basis that smooth the interface points within the complex matrix environment that includes UPMC, employed physicians, private practice, and multiple clinical sites. + Assume leadership role in the development of process improvement opportunities related to changes in clinical practice to support organizational goals. Apply innovative and creative skills to ensure that the process improvement opportunities are identified and addressed as well as meet the needs of quality and safety goals, and meets regulatory guidelines. + Works collaboratively with CQSI to ensure current and future obligations are met with respect to Public Reporting of quality outcomes. + Develop relationships and integrate all team members including physicians into the team's work. Report program findings, results, and changes at various settings and meetings. Form relationships with various setting in the continuum of care based on program issues/work. + Conduct an analysis of clinical variance trends and recommendations for clinical practice changes. Investigate and implement creative methods to improve process. + Provide leadership and preparation for Regulatory Compliance including DOH Licensure and Joint Commission Accreditation Surveys + Effectively participate and engage in activities to support and achieve organizational strategic goals including an analysis of quality programs and patient care outcomes. + Demonstrate an interactive leadership style that influences thinking and reshapes the quality environment. + Demonstrate a collaborative leadership role in the External Regulatory Survey process, to ensure compliance and continual readiness for accreditation and licensure surveys. + Lead multidisciplinary teams, as assigned, in the development and ongoing progress of clinical outcomes to achieve organizational objectives of reducing resource utilization while promoting quality patient outcomes. + Provide administrative oversight for Infection Control including surveillance, data collection, education, and collaboration to reduce HAI's. + Demonstrate responsiveness to the changing priorities and targets in the field of quality and patient safety. + Serves as Facility Contact for PHC4 and PHCQA. + Demonstrate initiative to address complex, high-risk problems and translate them into opportunities and challenges with all levels of management. + Provide input into CQSI data analytics development and reports. + Coach and advise professional staff in the formulation of their development plan. + Manage all human and financial aspects of the department to assure that standards for quality and cost effectiveness are met. Prepare annual man-hours; expense and capital budget for responsible cost centers based on an analysis of needs of patients, clinical programs, staff and physicians. + Collaborate with professionals across UPMC to identify and support joint educational opportunities to change clinical practice. Active participation on System Quality, Safety, Regulatory and Infection Control teams. + Master's Degree required + 7-10 years Healthcare Related Experience required, with 5-7 years Supervisor Experience preferred + Certification in related area of expertise preferred. Advanced interpersonal communications skills to assure a collaborative positive culture of quality and safety + Knowledge of various aspects of quality and process improvement through IHC, IHI, Lean Systems management and other techniques. + Experience in effective presentation of quality efforts to medical professionals of multiple disciplines + Excellent interpersonal skills and demonstrated Leadership qualities knowledge of Clinical Practices + Knowledge of regulatory requirements of multiple accrediting organizations including TJC, DOH and CMS Advanced analytic skills + Ability to effective and succinctly communicate verbally and in writing to all levels of the organizations **Licensure, Certifications, and Clearances:** CPHQ (Certified Professional in Healthcare Quality) preferred + Act 31 Child Abuse Reporting with renewal + Act 33 with renewal + Act 34 with renewal + Act 73 FBI Clearance with renewal **UPMC is an Equal Opportunity Employer/Disability/Veteran**