The Vice President of Quality and Safety leads, supervises and coordinates quality improvement, infection prevention, patient and associate safety, clinical risk management, regulatory and accrediting agency reporting and continuous survey readiness across the acute and ambulatory care spectrum. The VP of Quality and Safety will report to the System Chief Clinical Officer and will have a matrix reporting relationship with the System CMO and CNO. In addition, the VP of Quality and Safety will work in a dyad relationship with the VP of Clinical Performance and work closely with care site CMOs and CNOs as well as the CMIO.
Quality and Safety Leadership:
Develop system vision for quality in conjunction with system leadership.
Develop and maintain a process that engages Care Site leaders in the periodic assessment and prioritization of System-wide quality/safety initiatives and supports Care Site Leaders in achieving system Quality and Safety goals.
Assist the CMO/CNO in support the quality committees of the SCL System Board, Regional Boards, and Care Site Boards.
Improvement and Support:
Support the Ambulatory Quality Committees and their regional quality needs and provide alignment with the SCL Health Quality and Safety Committee;
Work with the Care Site Quality Committees and Performance Excellence Committees to support their local needs and create alignment with the SCL Health Quality and Safety Committee;
Assist the System Clinical Leadership in developing and supporting quality initiatives as desired such as a nursing quality committee.
Safety and Clinical Risk Management:
Supervise the System Director of Patient Safety and High Reliability Organizing to further the organizational journey to Zero Harm by establishing SCL health as a learning organization, integrating reliability concepts and drivers with organizational objectives and goals across the care continuum as well as non-clinical functions; ensuring a just culture and non-punitive response to errors while driving accountability.
Supervise the System Director of Associate Safety, developing and maintaining system wide programming for associate safety and reliability so as to identify and mitigate organizational risk, support action plans that enable care sites to meet safety goals and objectives
Supervise the System Director of Clinical Risk Management, to identify and mitigate organizational risk to safe patient outcomes
Maintain a strong and standardized patient safety response system improving system resiliency through prevention, detection and correction.
Regulatory Quality and Reporting and Infection Prevention:
Supervise the System Director of Quality in supporting the following functions: Continuous Survey Readiness, Regulatory and Accrediting Agency Reporting, Pay for Performance, and Infection Prevention
Regulatory & Accrediting Agency Reporting
Develop and maintain a quality measures abstracting services for our Care Sites and clinics that meets regulatory/accrediting reporting requirements for required publicly-reported measures under the direction of the Director, Quality Decision Support.
Develop and maintain an effective electronic clinical quality measurement (eCQM) process that meets regulatory/accrediting reporting requirements and can be expanded as necessary to meet new or changing reporting requirements;
Pay for Performance
Monitor, evaluate and improve performance on federal pay for performance and penalty programs (e.g., Value-Based Purchasing, Hospital-Acquired Conditions, Readmissions);
Work in collaboration with Payer Contracting & Strategy representatives to assess, negotiate, and perform on commercial pay for performance contracts;
Continuous Survey Readines
Assure that Care Sites have the necessary resources, tools, training, processes and support to maintain continuous survey readiness;
Provide technical assistance and consultation as requested for rectifying any regulatory or accreditation concerns;
Develop an effective program for the prevention, surveillance, response, to healthcare associated infections and outbreaks.
Support centralized surveillance processes
Support system policymaking for infection prevention
Support system prospective auditing and evaluation of infection risk
Support regulatory readiness for infection prevention including processes for high level disinfection.
Bachelor’s degree and Master’s degree in related field;
5 years’ experience as a VP or Director of Quality and Safety a large single site acute care facility.
2+ years’ experience as a VP of Quality and Safety of a region or multi-site health care facility
More than ten years healthcare experience
Advanced training and expertise in healthcare quality, safety, improvement methods and reporting
Demonstrates expert knowledge of improvement methods in the care site clinical setting
Demonstrates significant health care management and operational knowledge/experience with a focus on improving the quality and safety of care
Certified Professional in Healthcare Quality (CPHQ) or other related certification
Experience supervising associates and working with health care data issues, regulatory readiness, change management and process improvement.
Project management, High Reliability Organizing, Lean or other process improvement methodology
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SCL Health is a faith-based, nonprofit healthcare organization that operates eight hospitals, four safety net clinics, one children’s mental health center and more than 190 ambulatory service centers in three states – Colorado, Kansas and Montana. The health system includes 15,000 full-time associates and more than 500 employed providers.