Quality Worcester, Massachusetts


Position at UMass Memorial Medical Center

Everyone is a Caregiver


At UMass Memorial Health Care, Everyone is a Caregiver regardless of title. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health care system of Central and Western Massachusetts, and a place where we can help you build the career you deserve. We are more than 14,000 employees, working together as one health care system. And everyone, in their own unique way, plays an important part, everyday.

Requisition #: 204236
Department: Office Patient Safety/Quality
Grade: 28
Posting Date: July 22, 2020
Shift: Days
Status: Exempt
Union: non-union
Hours: 40 hours
Shift Length: 8 hours
Location: UMass Memorial Medical Center – University Campus

Position Summary:

Leads and manages UMass Memorial Medical Center- wide (UMMMC) quality, performance improvement, patient safety and regulatory compliance and sustainability efforts using a data-driven approach and which aligns with ongoing organizational strategic initiatives.  Leads and performs activities in select departments and divisions, related to performance improvement in patient care.  Scope of activities include quality and patient safety assessments, analyses, facilitation, information system solution identification, communication, and development and implementation of best practices.   

Major Responsibilities:

  1. Leads as a change agent, improvement advisor and facilitator. Manages change in a planned and productive manner.
  2. Leads and develops sustainable performance and process improvement strategies to align care, treatment, and services with evidence-based, experience-informed structures and processes.
  3. Builds and defends the business case for Quality and Safety considering return on investment (ROI), regulatory or contractual requirements, and strategic competitive advantages.
  4. Creates an environment to review, recommend, and adopt best practices as part of quality, safety, regulatory and/or performance improvement.
  5. Ensures practices, policies and activities are in compliance with the requirements of relevant regulatory/licensing/oversight bodies; and ensures their readiness for associated review, inspection, reporting, and application processes. This includes, but is not limited to, the Joint Commission and the Department of Public Health, and the Centers for Medicaid and Medicare.
  6. Facilitates development of priorities by: establishing criteria for priority assessment (volume, risk, problem prone processes); using data on past performance to assess gaps; using external drivers for consideration including new regulations, and standards; and leveraging performance improvement tools to create a matrix for priorities to aid in decision making.
  7. Establishes a learning system by fostering creativity, encouraging spread of patient centric and evidence-based innovations.
  8. Works in a variety of settings and determines key functions with the setting. Applies concepts of prioritization, evidence-based practice, and applicable performance monitoring tools.
  9. Coaches and/or mentors individuals and teams in performance improvement strategies.
  10. Improves the effectiveness and efficiency of the organization’s processes and operations through consistent identification of risks to the organization. Works collaboratively with Risk Management.
  11. Assesses, designs and evaluates Patient Safety and Regulatory processes.
  12. Leads the development and implementation of comprehensive strategies to minimize risks and establishes action plans to address problems when identified.
  13. Uses evidence-based tools and strategies to implement advances and improvement of risk factors that affect the safe delivery of healthcare (i.e. Health IT, adverse event reporting). Tools include Failure Mode and Effects Analysis (FMEA), Root Cause Analysis (RCA), Checklists, project plans.
  14. Analyzes and applies measures which are meaningful to project work.
  15. Identifies and displays appropriate measures to evaluate process improvement efforts.
  16. Works collaboratively with Quality Analytics and Applied Informatics
  17. Exhibits strong analytical skills to perform data analysis of qualitative and quantitative data, review statistical reports, identify data needs, while maintaining attention to detail.
  18. Facilitates analysis and interpretation of outcomes data for the organization.
  19. Fosters an organizational culture of quality and safety, including emphasis on an environment of psychologic safety.
  20. Participates in regulatory survey procedures and works collaboratively with regulatory agencies and the community we serve.
  21. Educates the management team related to functional interrelations associated with regulatory and accreditation requirements.
  22. Participates actively in the organization’s annual self - assessment of patient quality and safety through the Intracycle Monitoring Process (ICM).
  23. Conducts tracer activities with Senior Leaders to support ongoing regulatory readiness and commitment in achieving the organization’s performance standards.
  24. Supports Medical Center committees as requested or required. Leads meetings of physicians, nurses and caregivers related to project work.

Position Qualifications:

  1. Master’s degree in public health, health care administration, business administration or related area required, or Bachelor’s degree required with employee currently enrolled in a qualified master’s level degree program.


  1. Clinical degree.
  2. Certification in Healthcare and/or Quality.



  1. Five years related experience.
  2. Strong knowledge of clinical processes and operations in a health care system.
  3. Demonstrated leadership and project management skills, proficiency in statistical quality control techniques, operations analysis and quality management
  4. Excellent verbal and written communication skills.
  5. Must be proficient in utilizing various computer software packages, including word processing, spreadsheets, relational databases, and graphic tools.

Standards of Respect:

Standards of Respect
We’re striving to make respect a part of everything we do at UMass Memorial – for our patients and for each other. We’re expecting that our new caregivers practice our six Standards of Respect: Acknowledge, Listen, Communicate, Be Responsive, Be a Team Player, and Be Kind, to help us make respect a part of how we take care of business everyday.

As an equal opportunity and affirmative action employer, UMMHC recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives and backgrounds. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, gender identity and expression, protected veteran status or other status protected by law.

If you are unable to submit an application because of incompatible assistive technology or a disability, please contact us at talentacquisition@umassmemorial.org. We will make every effort to respond to your request for disability assistance as soon as possible.