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Director Quality and Patient Safety HUP Path & Lab Medicine

Job ID: 219862
Category: Management/Leadership
Work Type: FT
Location: Philadelphia, PA, United States
Work Schedule: M-F

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Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.

Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?


  • The Director of Quality and Patient Safety for the Hospital of the University of Pennsylvania (HUP) department of Pathology and Laboratory Medicine (including divisions of Clinical Pathology, Anatomic Pathology, Hematopathology, Transfusion Medicine, Precision and Computational Diagnostics, Phlebotomy and Client Services) is responsible for the quality and safety standards of the department. In partnership with the Department Chair, CLIA Director(s), Vice Chair for Quality, Associate Vice Chair(s), COO, and Sr. Director of Clinical Operations, the incumbent will lead department-wide activities to optimize efforts in quality, continuous improvement, regulatory compliance, safety, development of policies and procedures and dashboards and quality reports consistent with the Performance and Quality Improvement (PQI) goals of the Department. The Director of Quality and Patient Safety ensures operations and services provided are the expectations of the hospital and clinical customers. The Director of Quality and Patient Safety directs, oversees, plans, coordinates and evaluates our comprehensive program to improve clinical outcomes, enhance value, and minimize patient harm. The incumbent will develop tools, systems, processes and lead teams to assist with quality and safety efforts at all HUP affiliates including HUP Cedar, Radnor, Bucks County, Valley Forge and Rittenhouse locations. The Director of Quality and Patient Safety also represents these functional areas to the organization at large and external entities. Participates in hospital/health system committees to represent lab regulatory readiness, performance improvement, risk management or other relevant issues as needed to assist in achieving process or function changes. Assists other health system entities as requested.


  • Quality Assurance and Continuous Improvement: Monitors and implements standards development, re-engineering efforts, innovation, and continuous quality improvement. Recognizes potential barriers to implementation and develops a change management strategy in partnership with operations staff and leadership. Collaborates with representatives from other departments and other entities to support or initiate changes in operational systems which will improve delivery and quality of patient care and/or improve efficiency. Provides recommendations to the departmental leadership and assists the Administrative Directors in implementing agreed upon improvements to optimize the structure and service of our evolving Penn Lab (Health System Laboratory) concept. Assists on health system initiatives as requested.
  • Safety: Works with hospital, employed physician groups, affiliated physician practices, and other clinical and administrative staff to standardize quality and safety efforts in P&LM. Works with laboratory directors on the design, implementation, and oversight of an effective Quality Management System, including selected quality indicators and annual assessment. Directs the development of quality policies. Reviews emergency preparedness plans to ensure there is a comprehensive and robust process among the lab service units that will support patient care needs in the event of a major or minor disaster, public health crisis or other adverse event.Leads annual assessment of QMS, complaints and incidents with development and implementation of plans of corrective action. Assists and monitors the department’s efforts to maintain a safe working environment through development of safety policies, ongoing surveillance of environment and work practices. Ensures deficiencies noted are corrected.
  • Regulatory Compliance: Leads the maintenance of quality assurance standards and requirements for the departmental regulatory aspects of pathology e.g. CMS, DOH, CAP, CLSI, TJC, OSHA, NRC, DEA, FDA and DOT. Maintains database and monitors changes in regulatory requirements from governmental and professional agencies. Functions as a laboratory liaison for hospital regulatory and accrediting/regulatory agencies in preparation for inspections, site visits, documentation of compliance, deficiency corrections, status changes and licensing renewals. Conducts regular internal compliance audits. Works closely with project teams on creation and licensing of new lab operations across the Health System to ensure the new lab meets all regulatory start-up and ongoing compliance requirements. Acts as an advisor that troubleshoots and resolves regulatory issues across all functional areas. Provides feedback to Faculty and Administrative Directors on non-conformities. Creates and assesses corrective action plans to ensure revalidation of optimum performance. Provide support as requested by divisions with specialty specific accreditations (e.g., FACT, AABB, ASHI).
  • Data Management: Provides Department Leadership with a uniform format for establishing performance metrics, data collection and evaluation criteria to assess outcomes in PQI and risk management, and a dashboard system to summarize performance for all entity lab services on a quarterly basis as well as early alerts on data trending in an unfavorable direction or singular events that require immediate attention. Provides departmental and hospital leadership with a summarized dashboard of each lab service performance measures. Strengthens the data and information capabilities of pathology through governance and championship of a data-driven environment. 

Education or Equivalent Experience:

  • Bachelor of Arts or Science (Required) with 10 years of clinical lab experience.
  • 3+ years of experience in quality and/or regulatory management experience. 
  • LEAN or SSBB (Preferred)
  • ASCP certification (Preferred)

We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.

Live Your Life's Work

We are an Equal Opportunity and Affirmative Action employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.

   Current UPHS employees must apply HERE
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