Facility: WCO - Wellstar Corporate Office

Job Summary:

The Assistant Vice President (AVP) Safety and Quality reports to the Vice President Quality and Safety at WellStar Health System. As a member of the leadership team, he/she 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 in acute care facilities, and/or service lines, and/or ambulatory care sites and/or quality and safety and infection prevention departments 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. They will maintain a 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. They will influence 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. They will serve as a spokesperson and is generally recognized as the strategy owner and subject matter expert.
The AVP Quality and Safety participates as an active part of WellStar's leadership team in developing and implementing System strategic plans and initiatives. They 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.

Core Responsibilities 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
* Infection Prevention
* Service line and ambulatory care quality
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.
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
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.)
Performs other duties as assigned
Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

• Bachelors Nursing or Bachelors Health Science or Bachelors Other
• Masters Health Administration or Masters Business Administration/Management or Masters Other

Required Minimum License(s) and Certification(s):

All certifications are required upon hire unless otherwise stated.

Additional License(s) and Certification(s):

CPPS - Cert Prof in Patient Safety within 2 years Required or
CPHQ - Cert Prof Healthcare Quality within 2 years Required or
RN - Reg Nurse (Single State) or RN-COMPACT - RN - Multi-state Compact Upon Hire Preferred and

Required Minimum Experience:

Minimum 10 years Experience in healthcare Required and
Minimum 5 years Formal leadership and management of teams with direct reporting relationships Required and
Minimum 5 years Oversight of Quality Management, Patient Safety, and High Reliability Organizing programs Required and
Demonstrated experience and knowledge of CMS and state and federal healthcare regulations Required and
Demonstrated ability to improve public report cards measuring quality and patient safety Required and
Expertise in fair and just culture programs Preferred and
Expertise in Lean Improvement methods and project management Preferred and
Expertise in Vizient quality measures Preferred and
Expertise in ambulatory care and service and population health quality metrics

Required Minimum Skills:

Knowledge and application of safety science, analysis (common cause and root cause), measurement, and improvement methods. High
Ability to develop collaborative relationships and effectively execute project management plans and lead culture change High
Excellent communication/presentation skills, flexibility, ability to multi-task, organization skills to support a multi-hospital system. High
Ability to manage comprehensive quality plan and achieve stellar results High
Proven expertise in coordinating specialty certification such as total joint, stroke, and disease specific classification. Medium
Direct experience with managing performance improvement teams and workgroups. High
Ability to manage a diverse team in a manner that imbues trust and supports a fair and just culture. High
Direct experience with developing and implementing Joint Commission Evidence of Standards compliance for hospital accreditation and disease specific care. Low
Ability to interpret regulations and standards (CMS, State, Joint Commission, DNV) Medium
Ability to understand methodology of quality and safety measurement models of external rating agencies (including but not limited to Vizient, Leapfrog, CMS, State, US News) High