Reporting to the Chief Medical Officer (CMO), this key position is responsible for the strategic and innovative development, planning, implementing the patient safety and quality improvement initiatives throughout CentraState Healthcare System Services. This position coordinates System-wide activities to ensure compliance with standards, accreditation and regulations (i.e. Federal, State, Joint Commission, and CMS). A critical factor to ensuring achievement is the proactively address patient safety issues utilizing and interpreting data from various sources (i.e. Crimson, Nuance, NCQI); determine root causes; and through collaboration and partnership with key stakeholders develops programs and services that produce measurable improvements in processes and practices affecting quality and/or patient safety.
This position requires conceptual, analytical and statistical skills, effective communication skills, excellent interpersonal skills and proven leadership. Provides the vision, strategy and leadership necessary to support successful execution of the CentraState’s mission, vision and strategy. As a member of the Executive Leadership Team, the AVP Quality & Patient Safety is tasked with leveraging continuous quality improvement to ensure CSHS exceeds patient safety standards, Core Measures and Value Based Purchasing. Anticipates and otherwise keeps pace with evolving market and organizational demands and likewise, provides service levels commensurate with best industry practices.
- Oversees and coordinates the development of Performance Improvement and Quality Control Plans and provides system wide report on relevant performance indicators.
- Acts as the staff liaison to the Quality Council and the Quality of Patient Care Board Committee (QPC) coordinating the monthly meetings by setting the agendas, providing reports and minutes on timely basis.
- Monitors departmental and system operation working closely with department management (including clinical chairs) and leads efforts necessary to optimize the quality of patient care and services provided. By monitoring industry and statistical benchmarks, assures there is an effective and accountable process to set specific Performance Improvement objectives.
- Ensures on-going quality and patient safety monitoring activities are implemented in high risk areas. Provides meaningful data analytics to manage, forecast and drive performance of our quality and patient safety programs.
- Develops annual System Performance Improvement Plan
- Acts as system resource for completing root cause analysis and critical self-analysis, to improve processes involved in a sentinel event.
- Collaborates with CDI Specialists and HIM professionals to ensure the quality of patient documentation accurately reflects the quality of care provided
- Tracks, reports and oversees on-going analysis of system wide performance improvement activities; including but not limited to, Value Based Purchasing , Leapfrog
- Coordinates system activities to ensure compliance with standards and regulations of the State, Joint Commission and other external entities.
- Responds to specific patient related quality complaints from regulatory agencies and third party payers.
- Chairs the Joint Commission Readiness Committee on a regular basis.
- Leads the Infection Control staff, works as a team with Nursing and Ancillary Departments to facilitate effective and appropriate infection control practices.