AVP, Patient Safety & Quality
Location
Marietta, GA | United States
Job description
Overview The Assistant Vice President (AVP) Safety and Quality reports to the Vice President Clinical Outcomes at Wellstar Health System. As a member of the leadership team, this individual is responsible for developing an executable plan to attain a world class patient safety & quality processes and procedures across the System. Bringing patient and clinical safety expertise, he/she will partner to identify opportunities for short and long term gains in standardization, reduction of variability and adherence to best practices. This leader shares accountability with clinical and operational leaders to achieve of safe, high-quality outcomes as measured by internal and external KPIs and reports.
The individual in this role will identify opportunities to optimize performance, build internal competencies and create a rigorous System approach to safety and clinical quality. The establishment of a culture of ownership, responsibility, and accountability will be a foundational characteristic for this role. He/she maintains strong positive relationships with team members, medical staff, senior leaders, and patients.
The AVP is responsible for planning and implementation of clinical safety, high reliability organizing (HRO), quality management and public reporting programs and initiatives. The person influences the policies and practices of internal and external partners to optimize Wellstar's success.
The AVP recommends and administers the overall departmental business plan and budget for safety, quality and public reporting under the direction of the VP. He/she serves as a spokesperson and is generally recognized as the strategy owner and subject matter expert.
The AVP participates as an active part of Wellstar's leadership team in developing and implementing System strategic plans and initiatives. This AVP will be an active leader to drive a culture change that is visible to every level in the organization, incorporating messaging that is consistent and creates ownership for safety and quality by every employee.
Responsibilities Core Responsibilites and Essential Functions
- Effectively develops, executes, monitors and adjusts the organization's long- and short-term strategic plans relevant to the role:
* Patient Safety
* High Reliability Organizing (HRO)
* Quality Management
* Public Reporting programs related to clinical quality - Oversees and directly participates in the execution of the Patient Safety/HRO plan:
* Identifies and incorporates effective elements of a contemporary Patient Safety & HRO program into the Wellstar program and standards.
* Directs Safety Event management across the organization. Including but not limited to: event reporting systems & mechanisms, event classification, causal analysis, establishing effective corrective actions, and timely reporting of events & trends.
* Establishes and incorporates safety and HRO training as appropriate and in partnership with Organizational Learning and other key stakeholders. Audience for the curriculum includes all levels of leadership, team members and providers.
* Collaborates with the Data Insights team and subject matter experts to identify, analyze and report relevant data with actionable insights
* Incorporates best practices for building and sustaining a fair and just culture of safety and performance excellence
* Identifies and supports high priority patient safety initiatives across the continuum of care
* Assesses program/initiative effectiveness and reports routinely to senior leadership regarding progress, risks and barriers - Oversees and directly participates in the execution of the Quality Management & Improvement plan:
* Establishes standards and coordinates business unit annual Performance Improvement Plans
* Serves as an expert resource for Quality Management related metrics, definitions, dashboards and reports. Including but not limited to Wellstar's clinical benchmarking databases and dashboards.
* Maintains a current and expert knowledge of external, publicly reported measures of quality. Including methodology, results and best practices for improvement.
* Coordinates quality improvement efforts across business units, the continuum of care and shared system departments for the purposes of alignment, synergy and effectiveness.
* Oversees Wellstar's public reporting programs including data abstraction and submission to CMS, Accrediting agencies, and specialty registries. Coordinates responses and established strategies for improvement related to quality and patient safety surveys (e.g. Leapfrog and QHIP).
* Ensures compliance with CMS, State and Accrediting agency requirements related to the provision of transparent information to the governing body.
* Engages and advises senior leadership in matters related to quality management risks, opportunities and plans for improvement. - Administrative duties related to the management of the Safety & Quality, Medication Safety, and Public Reporting shared services departments.
Participates in annual budgeting process. Monitors and adjusts expenditures to manage within the approved departmental budget.
Evaluates, coaches, mentors and manages the workforce for optimal individual and team contribution
Other managerial duties (recruitment, hiring, evaluations, departmental policy development, etc.)
Required for All Jobs
- Performs other duties as assigned
- Complies with all Wellstar Health System policies, standards of work, and code of conduct.
Qualifications Required Minimum Education
- Bachelor's Degree in Healthcare, Nursing, or other healthcare field Required and
- Master's Degree in healthcare or management related discipline Required
Required Minimum Experience
- Minimum 10 years Experience in healthcare is Required and
- Minimum 5 years Formal leadership and management of teams with direct reporting relationships is Required and
- Minimum 5 years Oversight of Quality Management, Patient Safety, and High Reliability Organizing programs is Required and
- Demonstrated experience and knowledge of CMS and state and federal healthcare regulations is Required and
- Demonstrated ability to improve public report cards measuring quality and patient safety Required and
- Expertise in fair and just culture programs is Preferred and
- Expertise in Lean Improvement methods and project management is Preferred
Required Minimum Skills
- Knowledge and application of safety science, analysis (common cause and root cause), measurement, and improvement methods.
- Ability to develop collaborative relationships and effectively execute project management plans and lead culture change
- Excellent communication/presentation skills, flexibility, ability to multi-task, organization skills to support a multi-hospital system.
- Ability to manage comprehensive quality plan and achieve stellar results
- Proven expertise in coordinating specialty certification such as total joint, stroke, and disease specific classification.
- Direct experience with managing performance improvement teams and workgroups.
- Ability to manage a diverse team in a manner that imbues trust and supports a fair and just culture.
- Direct experience with developing and implementing Joint Commission Evidence of Standards compliance for hospital accreditation and disease specific care.
- Ability to interpret regulations and standards (CMS, State, Joint Commission, DNV)
Required Minimum License(s) and Certification(s)
- Certified Professional in Patient Safety (CPPS) - Required
- Certified Professional in Healthcare Quality (CPHQ) - Required
- Registered Nurse (RN)- single state or compact - Preferred
We’d like to invite you on a career journey like no other! In return for your contributions, we’ll help you make the most of all life’s moments – on and off the job. Wellstar Total Rewards is designed to provide for your total well-being, including: Your Wellness, Your Pay, Your Future, Your Joy. We think it’s pretty simple – we care for our team members and our team members care for the community.
Make a difference in patients’ lives… and your own! Here, it’s more than healthcare – it’s CareerCare!
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