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Job Summary

Responsible for the development, measurement, and sustainability of a UH/CVC segment quality and patient safety program; with an aim of reducing preventable harm and producing quality outcomes by assisting others in identifying, assessing, and analyzing systems and processes to mitigate risk by focusing on high reliability principles. Coordinates hospital-wide patient safety initiatives. Ensures patient safety projects are aligned with the organizational and hospital strategic goals. Involved in leading an overall segment safety strategy with a focus on hospital identified priorities including hospital-acquired conditions, error prevention, leadership methods, and cause analysis. Acts as a change agent to lead, facilitate, and support hospital and medical staff to create and sustain a culture of high reliability.  Manages and oversees the coordination of the segment daily Safety Huddle and ensures processes are in place for appropriate follow up, resolution, and communication. Ensures quality and safety efforts are integrated with the Hospital Operating System and there is an appropriate flow of quality and safety information between Safety Huddle, Leadership Huddle and unit/department DMS huddles.


Supervision Received

This role reports directly to the UH/CVC Chief Nurse Officer, with functional supervision provided by the UH/CVC Executive Triad and Strategic Advisor.  This position is a member of the UH/CVC Segment Central Project Management Team.

Supervision Exercised

Supervision may be exercised over students and summer interns or others as designated.

Mission Statement

Michigan Medicine improves the health of patients, populations and communities through excellence in education, patient care, community service, research and technology development, and through leadership activities in Michigan, nationally and internationally.  Our mission is guided by our Strategic Principles and has three critical components; patient care, education and research that together enhance our contribution to society.


  • This position will work with individuals at all levels of the UH/CVC segment on executing plans to improve key performance metrics in categories including, but not limited to: patient safety, quality & regulatory, waste reduction, patient experience, and colleague engagement.

  • Functions as a key contributor in developing a comprehensive program to minimize patient harm through the implementation of systems that create a culture of safety; proactively identify risk; encourage adverse event reporting and thoughtful, learning-oriented analysis of safety events and near misses.

  • Participates in the development, implementation and/or revision of procedures and protocols in accordance with system-wide goals and objectives.

  • Works collaboratively with other segments and departments as a member of various system-wide committees. Serves as key liaison and change agent to all healthcare services, nursing, clinical, and administrative departments, medical staff, and committees throughout UH/CVC.  Forms relationships quickly at all levels in the organization to ensure effectiveness.

  • In conjunction with the UH/CVC Quality & Safety Committee co-chairs, coordinates and facilitates the UH/CVC Quality & Safety Committee.  Establishes & executes standing calendar of reports by relevant segment stakeholders.  Ensures appropriate follow up recommended by the committee occurs.

  • Coaches/mentors others on high reliability systems and processes.

  • Assists in identifying opportunities for quality and safety improvement through observation, data analysis, or other means, and engages multidisciplinary teams through appropriate Lean Six Sigma and PDCA processes to achieve improvements.

  • Provides expert advice and contribution for identified improvement initiatives; ensures plans are implemented by stakeholders

  • Ensures appropriate project management is utilized (project approval and charters, work breakdown structures, schedules, dependencies, resource assignments, tracking and analysis, risk/issues, mitigation strategies).

  • Provides guidance on appropriate report and dashboard documents, keeping stakeholders informed.

  • Collaborates with staff and leadership of various units and departments and provides education and training on the use of various process improvement tools and assists them with the appropriate utilization of these tools to reduce waste and promote transformative care.

  • Monitors activities to ensure compliance with applicable laws, regulations and Joint Commission requirements.

  • Implements external and internal audit recommendations.

  • Conducts analysis of the gap between current state and future state.

  • Utilizes advanced data and statistical analysis techniques.

  • Serves as an expert in the review, interpretation, and presentation of clinical outcomes data.

  • Uses spreadsheets, run charts, quality control charts, pareto graphs and other standard QI tools throughout data analysis and performance improvement projects.

  • Conducts advanced improvement activities through engagement of teams, subject matter experts, stakeholders and benchmarking.

  • Utilizes state of the art and the most appropriate, up-to-date continuous quality improvement methodologies to implement quality and safety activities throughout the UH/CVC.

  • Assists in identifying key metrics related to process improvement projects to ensure expected outcomes are being achieved, and continually monitors progress.

  • Identifies best countermeasures and combined solutions needed to address and or mitigate root causes.

  • Ensures evidenced-based best practices are at the center of improvement activities.  Facilitates the sharing of internal and external best practices across the segments. Collaborates with other Michigan Medicine segments in sharing safety successes.

Required Qualifications*

  • Master’s Degree required
  • 8+ years of healthcare experience required
  • A minimum of 3 years’ experience in planning, implementation, and evaluation of a comprehensive or large scale performance improvement program, preferably in a health care field.
  • Demonstrated expertise and knowledge of national standards and outcomes for quality, safety and healthcare such as CMS Core Measures & Value Based Purchasing, AHRQ PSI’s, Leapfrog, US News and World Report rankings.
  • Demonstrated change management skills and root cause analysis experience.
  • Strong communication, facilitation and presentation skills.  Ability to effectively communicate with staff from all levels of the organization.

Desired Qualifications*

  • Clinical experience as licensed healthcare professional is preferred, though candidates with MHA, MHSA, MBA, MPH, or MS will be considered if there is commensurate work experience in healthcare performance improvement.
  • Demonstrated hospital-based healthcare experience
  • Six Sigma Black Belt/Lean Certification/IHI Improvement Advisor/Certified Professional Health Care Quality/CPPS or equivalent experience.
  • Demonstrated experience in advanced data and statistical analysis techniques.

Background Screening

Michigan Medicine conducts background screening and pre-employment drug testing on job candidates upon acceptance of a contingent job offer and may use a third party administrator to conduct background screenings.  Background screenings are performed in compliance with the Fair Credit Report Act. Pre-employment drug testing applies to all selected candidates, including new or additional faculty and staff appointments, as well as transfers from other U-M campuses.

U-M EEO/AA Statement

The University of Michigan is an equal opportunity/affirmative action employer.