Mgr, Quality & Safety,Dept

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):

10 Miracle Mile Dr, Rochester, New York, United States of America, 14623

Opening:

Worker Subtype:

Regular

Time Type:

Full time

Scheduled Weekly Hours:

40

Department:

500282 Program Mgmt Orthopaedics

Work Shift:

UR - Day (United States of America)

Range:

UR URG 113

Compensation Range:

$77,216.00 - $115,824.00

Responsibilities:

GENERAL PURPOSE
Develops and implements programs, policies, and practices to ensure that all departments are in compliance with organizational and governmental standards and makes recommendations for updates. Maintains compliance with all country-mandated regulatory requirements. Documents legal regulations that might affect the organization's policies and procedures. Develops and delivers training programs to enhance employee 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. Develops programs and processes to manage complaint cases brought to regulatory authorities and develops process improvements to avoid future complaints. Sets priorities for the team to ensure task completion. Coordinates work activities and have accountability for the performance and results of team.

ESSENTIAL FUNCTIONS

• Acts as a Quality Assurance liaison to appropriate University departments as it relates to risk events, investigation, findings.
• Provides best practice recommendations to internal teams as appropriate.
• Reviews and investigates all safety related incidents in incident management system and reports to appropriate parties.
• Ensures appropriate review, follow up and associated operations implementations with monitoring for sustained improvement.
• Evaluates data and identifies trends regarding clinical risk.
• Provides reports and participates in task forces and committee meetings to develop risk mitigation strategies.
• Manages and provides oversight of reviews and findings for all grievances and patient complaints across the department's clinical programs involving quality of care, safety or patient rights violation allegations, with primary accountability for all written and verbal responses.
• Facilitates and participates in patient/family meetings with appropriate clinical leaders when indicated to provide support/closure.
• Monitors data for trends that require a more systemic approach to addressing patient experiences in care and treatment.
• Directs implementation of SMH Quality Plan in collaboration with department leadership, SMH Quality Office and CRMQIT to ensure internal and external requirements for documenting quality efforts are met.
• Provides oversight in ensuring appropriate staff and leaders follow up on recommended metrics and actions.
• Identifies opportunities for clarification and revision for department policies and procedures based on trended data from incidents, RCAs and Grievances.
• Drafts appropriate SOPs.
• Collaborates with Office of Counsel to coordinate and facilitate reportable events.
• Facilitates investigations/reviews to identify and implement sustainable risk reduction strategies and measures of effectiveness.
• May serve as chair of appropriate committee(s), including setting agenda, participating in and ensuring incident investigations are completed in a timely way and facilitating and coordinating systemic efforts to improve safety and reduce incidents through data and trend analysis, including high risk events and sentinel events with highly regulated internal and external reporting and corrective action planning (CAPS).

Other duties as assigned.

MINIMUM EDUCATION & EXPERIENCE

• Bachelor's degree and 5 years of relevant experience required
• Or equivalent combination of education and experience

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