Quality Improvement Leader

Company: Mapta
Location: Baltimore
Posted on: May 9, 2025

Job Description:

Job DescriptionUnder limited supervision, plans, coordinates, leads, and monitors quality improvement initiatives within clinical service departments and across the UMMC Downtown campus ('organization'). Communicates with organization leadership (Directors, Chairs, VPs, SVPs), clinical teams, and other departments (Performance Innovation, Infection Prevention, Nursing, etc.) to drive organizational change toward high reliability and Zero Harm. Ensures awareness of, and continuously implements, the UMMC Quality Assurance/Performance Improvement (QAPI) program and the Annual Operating Plan (AOP) goals. Provides leadership and direction to multi-disciplinary teams (including physicians and senior leaders) to collaboratively accomplish quality improvement strategies at UMMC. Accountable for overall quality of care provided to all patients in the designated clinical service departments, as well as compliance with quality requirements as outlined by CMS, Joint Commission, and/or disease-specific certifications. Collects and analyzes data, conducts presentations, provides consultation, and staffs and leads service-specific and organization-wide committees. Promotes UMMC on its journey to become a High Reliability Organization (HRO) through robust quality improvement tools and by promoting a Just Culture.The position encompasses various roles (e.g., subject matter expert, coordinator, educator, project manager, data analyst, facilitator), requiring effective interpersonal, management, and leadership skills. A working knowledge of clinical workflows and strong leadership skills are integral to gaining credibility and collaboration from colleagues. Duties include working with clinical service departments on quality improvement strategies to 1) enhance clinical/patient outcomes, 2) maximize financial rewards within Maryland's pay-for-performance programs, and 3) improve the organization's ranking within Vizient's Q&A dashboard. This role collaborates with organization leadership, staff, advanced practitioners, and physicians to systematically identify, measure, monitor, and evaluate quality activities to foster a Zero Harm environment and promote High Reliability principles. It also develops and maintains collaborative relationships with key medical staff, including Chairs, and serves as a vital quality improvement resource to clinical teams and support staff.

• Assists in coordinating and implementing activities toward becoming a high reliability organization with a focus on Zero Harm.
• Collaborates with leadership to direct and implement the bi-campus, integrated quality improvement program, including:
• Quality Program Management
• Oversees implementation of quality improvement initiatives for organizational performance, planning, organizing, leading, and directing activities within clinical service departments and organization-wide.
• Develops and leads projects addressing problem areas aligned with strategic priorities, including UMMC's QAPI, AOP goals, Maryland's pay-for-performance programs, and Vizient's Q&A dashboard. Projects may span both campuses.
• Collects, reviews, analyzes, and monitors performance data to identify trends impacting patient care and financial performance. Collaborates with leadership to prioritize quality improvement efforts.
• Leads and manages special projects by identifying resources, involved personnel, and project requirements, potentially across campuses.
• Ensures action plans are implemented to sustain improvements before transitioning to service line leaders for ongoing monitoring.
• Participates actively in organizational quality committees, including chair roles, covering various clinical and organizational initiatives, possibly across campuses.
• Leadership
• Works with staff, senior leaders, Chairs, and Lead Quality Physicians to set quality priorities aligned with organizational strategies.
• Partners with leadership to foster a culture of quality improvement and Zero Harm.
• Facilitates clinical review and problem-solving using methodologies like RCA, PDSA, Lean, and Process Improvement tools.
• Meets regularly with Lead Quality Physician to review departmental and organizational quality focus, data, and issues.
• Develops and delivers education on quality improvement methodologies and goals, contributing to communication channels like the Quality Matters Newsletter.
• Provides just-in-time training to support quality initiatives.
• Ensures quality projects stay on track with timelines and expected outcomes.
• Data Management
• Supports metrics related to Maryland's pay-for-performance and Vizient dashboards, including PPCs/PSIs, mortality, follow-up, and other quality-related metrics.
• Monitors indicators for trends and improvement opportunities aligned with strategic goals.
• Maintains accuracy of dashboards in collaboration with analytics teams.
• Analyzes data trends to identify opportunities for quality and safety improvements, potentially across campuses.
• Provides consultation to support departments in establishing quality indicators, analyzing data, and developing improvement plans.
• Provides leadership on regulatory compliance, including:
• Ensuring adherence to TJC and CMS standards related to QAPI.
• Participating in accreditation visits and real-time staff education during tracers.
• Overseeing actions in response to regulatory recommendations.
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Keywords: Mapta, North Bethesda , Quality Improvement Leader, Other , Baltimore, Maryland