VP QUALITY IMPROVEMENT & SAFETY
Company: West Park Hospital-WY-US
Posted on: April 11, 2021
The VP of Quality Improvement and Safety provides leadership and
direction to System-wide quality and safety programs, focusing
efforts on outcomes which improve the quality of care,
patient/resident safety and satisfaction, and efficiency of patient
care across the System. Works collaboratively with members of
senior management and physician leaders at the corporate and local
levels to design and implement operational strategies and tactics
to improve the outcomes desired. Responsible for managing readiness
and compliance with regulatory agencies. Oversees all safety
related programs and national patient safety goal implementation
and compliance. Duties and Responsibilities
- Advances the System's quality program by continuing development
of the program's infrastructure; develops information and tools
which can be used for the purposes of analyzing and monitoring
quality of care, including indicators of outcomes and
cost-effectiveness of patient treatment processes; develops action
planning, including training programs, designed to improve
performance on system-wide quality indicators.
- Develops quality and safety related goals and objectives to
support the system's operating strategies and mission. Develops and
implements initiatives to reach these goals and objectives.
- Responsible for system-wide compliance with all clinical
regulatory agencies, including CMS, DNV, state departments of
public health and state nursing home regulators. Represents
Covenant Health before such agencies.
- Works with members of management to develop decision-support
tools for clinical resource and patient management; works
collaboratively with clinical leaders for the development of
clinical pathways which support efforts to improve quality and
- Attends, participates and supports the Board Quality and Safety
Committee; works closely with and supports the Committee's Chair;
monitors the ongoing Quality initiatives for the system and reports
on such at Committee meetings.
- Oversees data-driven performance improvement in the areas of
quality, safety, and efficiency of care delivered across the
- Keeps abreast of changes in health care regulations, quality
standards, publicly reportable performance indicators, value-based
purchasing metrics and pay-for-performance indicators.
- Oversees and works to improve Covenant performance on all
publicly reported and value-based purchasing metrics related to
quality, safety, and efficiency of care.
- Responsible for metric choices for and maintenance of all
quality, safety and efficiency dashboards. Assures accurate and
timely compilation of metric data and insertion into each
- Supports member organizations in their continuous efforts to
improve quality and patient safety within their respective
organizations. Periodic and regular travel to Covenant facilities
will be required as needed.
- Fosters effective relationships and strategic partnerships with
external bodies involved with quality and safety, including
professional organizations, associations, and non-profit
- Fosters strong working relationships and close partnerships
with clinical, quality risk and other leaders at all Covenant
facilities with the goal of effectively driving change to
continuously improve the quality of care delivered.
- Knowledgeable of and experienced with the principles of high
reliability and utilizes these principles on a daily basis to
continuously improve quality and patient/resident safety.
- Represents Covenant effectively and credibly in a variety of
forums and venues relating to patient safety and quality of care.
Act as liaison to administration, medical staff, and outside
agencies relative to quality/performance improvement
- Works closely and collaboratively with Risk Management
Leadership on system-wide adverse event investigating and
reporting, including root cause analyses.
- Responsible for developing and updating the annual Covenant
Quality Improvement Plan.
- Directly oversees the System Directors of IMG Quality,
Post-Acute Quality, and Infection Prevention, as well as the
Quality Data and Midas Managers.
- Abides by the Standards of Conduct which is the basis for the
Organizational Integrity Program.
- Supports and Promotes the mission and values of Covenant Health
Systems and the Catholic Health Ministry. Qualifications
- RN degree required, with clinical and management
- Master's degree in healthcare related field required.
- PCHQ certification required, or eligible to obtain within one
- Minimum of 5 years of progressively more responsible experience
in healthcare quality monitoring and analysis, preferably in a
multi-location healthcare system.
- Experience in managing quality and safety in acute, post-acute
and ambulatory settings strongly preferred.
- Ability to foster a cooperative work environment with all
constituents across all Covenant facilities.
- Interpersonal skills necessary to represent the system to the
public and interact effectively at all levels of the
- Knowledge of the healthcare industry and the processes and
procedures that take place across the healthcare continuum.
- Knowledge of federal, state and local safety regulations,
protocols, and/or procedures.
- Ability to provide technical guidance and leadership to
professional personnel in all areas of quality and safety. Job
knowledge and skills
- Demonstrable commitment to the highest standard of ethical and
- Demonstrates expertise in data management and the use of
analytical and statistical tools to identify trends in current
processes and systems.
- Skill in effective application of CQI teams, quality measures,
clinical guidelines, and process management initiatives.
- Skill in consistently meeting reporting requirements of NCQA,
HEDIS, CMS, ACO and other regulators and accreditors.
- Outstanding organizational and project management
- Computer skills in Microsoft Office (Word, Excel, Access,
PowerPoint and Outlook) for email, scheduling, and navigation of
the organization's computer systems.
- Excellent verbal/written communication and interpersonal
- Skilled in facilitation, presentation and negotiation.
- Skilled in using system software effectively to produce trend
analysis, evaluation data, and documentation.
- Analytical and problem-solving skills and excellent judgment a
- Ability to work under pressure with challenging deadlines;
adaptability and flexibility required. We are a Catholic health
ministry, providing healing and care for the whole person, in
service to all in our communities. Our Core Values: We show
respect, caring and sensitivity towards all, honoring the dignity
of each person, especially the poor, vulnerable and suffering. We
promote justice and ethical behavior, and responsibly steward our
human, financial and environmental resources. We work in
partnership, dialogue and shared purpose to create healthy
communities. ---Excellence We deliver all services with the highest
level of quality, while seeking creative innovation. We are an
equal opportunity, affirmative action employer and all qualified
applicants will receive consideration for employment without regard
to race, color, religion, age, disability status, gender, sexual
orientation, ancestry, protected veteran status, national origin,
genetic information or any other legally protected status.
Keywords: West Park Hospital-WY-US, Boston , VP QUALITY IMPROVEMENT & SAFETY, Executive , Tewksbury, Massachusetts
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