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 and Risk Reduction Strategies + Joint Meeting on Quality of Care – board quality meeting to review hospital QAPI activities + Quality Improvement Coordinating Center meetings and assignments + Departmental QA Case Review meetings and QAPI plan reviews **Investigates and Analyzes Quality and Patient Safety** + Investigates circumstances of cases with adverse patient outcomes, or potential for adverse outcomes. Coordinates with clinical departments and service lines to identify associated improvement strategies to improve patient safety. + Investigates Severe event reports and assignment of appropriate follow-up. Coordinates with clinical departments and service lines to identify associated improvement strategies to improve patient safety. + Facilitates case reviews and root cause analyses, with reporting to NYPORTS as appropriate. + Facilitates interdisciplinary review of care, as appropriate. + Uses process improvement tools and methods, such as lean improvement, FMEA, RCA, in order to improve the quality of care and patient safety. **Additional Responsibilities** **Supports the hospital’s regulatory compliance goals by acting as liaison between external agencies and the hospital:** + Manages external surveys and case investigations including Joint Commission, NYSDOH, IPRO, and CMS + Responds and reports to external regulatory agencies. + Manages the New York Patient Occurrence Reporting and Tracking System (NYPORTS) **Carries out additional responsibilities as necessary in supporting Hospital-wide quality assurance efforts, such as:** + the development of policies, forms, etc. + development of changes to the electronic medical record to support patient safety and meet regulatory requirements Other duties as assigned **QUALIFICATIONS** + Bachelor’s degree required; + Master’s degree preferred; + Area of study in a health-related field preferred. + 5 years of relevant experience required; + or equivalent combination of education and experience required. + Experience in Healthcare Quality, Healthcare Performance Improvement or Healthcare Quality Assurance preferred + Knowledge of MS Office, Tableau, and data analytics preferred + Strong communication and interpersonal skills required; + Ability to maintain confidentiality required; + Strong critical thinking skills and attention to detail required; + Knowledge and understanding of clinical quality improvement, quality assurance, federal and state regulations required. + CPHQ or CPPS preferred **EOE Minorities / Females / Protected Veterans / Disabled:** The University of Rochester is committed to fostering, cultivating, and preserving a culture of equity, diversity, and inclusion to advance the University’s mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion/creed, sex, sexual orientation, citizenship status, or any other status protected by law. This commitment extends to the administration of our policies, admissions, employment, access, and recruitment of candidates from underrepresented populations, veterans, and persons with disabilities consistent with these values and government contractor Affirmative Action obligations. Notice: If you are a **Current** **Employee,** please **log into myURHR** to search for and apply to jobs using the Jobs Hub. Your application, if submitted using this portal, cannot be moved forward. **Learn. Discover. Heal. Create.** Located in western New York, Rochester is our namesake and our home. One of the world’s leading research universities, Rochester has a long tradition of breaking boundaries—always pushing and questioning, learning and unlearning. We transform ideas into enterprises that create value and make the world ever better. If you’re looking for a career in higher education or health care, the University of Rochester may offer the perfect opportunity for your background and goals At the University of Rochester, we commit to diversity, equity, and inclusion and united by a strong commitment to be ever better—Meliora. It is an ideal that informs our shared mission to ensure all members of our community feel safe, respected, included, and valued.