Performance Expectation:Quality and Safety

Responsibility to Enterprise:

• Design, implement, evaluate, and refine the mission, vision, and strategic plans of VCUHS' Safety and Quality Departments and Programs.

• Ensure compliance with required reporting of quality and safety metrics to governmental and regulatory agencies.

• Lead activities to support VCUHS' enterprise-wide goal of being nationally recognized for providing safe care for all its patients.

• Appropriately align and benchmark VCUHS outcomes and goals to other organizations nationally.

• Ensure that quality and clinical safety training programs are aligned with high reliability concepts, and are created, delivered, and managed according to internal and external guidelines.

• Establish measurements for internal stakeholders and assure reporting of relevant quality and clinical safety metrics to all required external entities, including federal and state.

• Champion and lead quality and outcomes management initiatives across VCU Health that incorporate best practices, create efficiencies, reduce variation and decrease cost.

• Guide and define methodologies for quality and clinical safety improvement.

• Foster implementation of best practices for patient safety and quality.

• Implement and lead evidence-based practice and programs to drive continual quality and clinical safety improvement.

• Oversee the dissemination of meaningful clinical safety and quality reports to key stakeholders.

• Closely collaborate with Health System leadership and clinicians while ensuring a multidisciplinary and organized approach to care practices.

• Foster an environment that supports learning and accountability.

• Oversee identification and analysis of serious safety events and implementation of corrective actions.

• Utilize systems thinking, human factors, complexity science, principles of epidemiology and performance improvement to prevent and mitigate risks to patients and team members.

• Oversee the development and implementation of surveillance programs and databases that track hospital acquired infections (HAI) and other adverse outcomes.

• Oversee the design and implementation of data-driven, cost-effective interventions to reduce HAIs and occupational exposures.

• Ensure that quality and clinical safety programs and interventions are based on sound principles of epidemiology and offer meaningful potential to improve clinical outcomes and ideally, decrease costs.

• Promote a culture that supports timely reporting of errors and near-miss events, open discussion of health care-associated failure events at all organizational levels, and the value of approaching these events as learning opportunities.

• Maintain a clinical practice in area of specialty; 80/20 admin/clinical, respectively.

• Support quality education and consultation to patients, families, visitors and healthcare teams.

Responsibility to Direct Department:

• Demonstrate personal ownership and accountability for quality and clinical safety.

• Support Health System reporting of events and near misses. Facilitate timely evaluation of clinical safety events and implement planned corrective actions.

• Promote safe behavior within the VCU Health System; take caution to ensure that VCU Health System team members apply safe behaviors to their everyday work.

• Establish a Health System environment in which staff are encouraged and supported to speak up for safety. Look beyond human and team behavior to consider problems with technology, policies, systems, and clinical environments as possible contributors to medical errors and adverse events. Proactively identify quality and safety problems and take effective action to address them.

Performance Expectation:Talent Strategy and Management:

• Establish and integrate a collaborative and accountable department to System goals and objectives.

• Develop guidelines and procedures for the management of Safety and Quality leaders to ensure the mission and vision of VCUHS is supported and enhanced.

• Supervise and evaluate quality leaders in collaboration with VCUHS business leaders.

• Provide oversight/input into the quality and clinical safety performance of the clinical medical directors, in conjunction with the CMO.

• Effectively manage a diverse workforce by demonstrating awareness and appreciation of cultural differences.

• Assist staff in developing awareness/appreciation skills to address cross-cultural issues.

Performance Expectation:Visibility (Strategy)

• Evaluate and advise senior leadership on the potential impact of proposed programs/strategies and regulatory action on quality and clinical safety at VCUHS.

• Partner with VCUHS Leaders, to conceive, shape and drive effective initiatives to improve quality and clinical safety.

• Foster an environment of continuous quality improvement, innovation, and agility.

• Translate strategic and tactical business plans into effective clinical safety and quality initiatives.

• Work candidly and collaboratively with VCHUS' CEO and senior leadership team.

Performance Expectation:Miscellaneous Responsibilities

• Perform other duties as assigned.

• Able and willing to participate or lead special projects in support of VCUHS and the incumbent's Department.

• Assist team members when required.

• Accept alternate assignments when necessary to fulfill business needs.

Patient Population

Not applicable to this position.

Employment Qualifications

Education/training Required:
Medical degree (MD or DO)

Licensure/Certification Required:
Must be board certified in their specialty or discipline, and within one year of hire, obtain and maintain licensure to practice in the Commonwealth of Virginia

Licensure/Certification Preferred:

Diversity, Equity, and Inclusion certification preferred

Minimum Qualifications

Years and Type of Required Experience:

Required: 10 years of progressive leadership experience in a complex academic medical center or Council of Teaching Hospital member institution; or demonstrated quality leadership in a non-academic healthcare setting, but with a strong professional publication record.

Preferred: 15 years of related leadership experience to include executive level experience specific to functional area.

Other Knowledge, Skills, and Abilities Required

• Experience establishing mid- and long-term strategic and operational goals for quality and clinical safety that align with organizational goals.

• Experience strengthening and reinforcing a culture of quality, clinical safety, and value across organizations.

• Demonstrated and measurable track record of leading and significantly improving quality and clinical safety in a hospital/system by using efficient and lean methodology.

• Experience in working with medical staff and all staff in areas of compliance, performance improvement, or clinical safety.

• Demonstrated and measurable experience in improving physician engagement and developing quality leadership.

• Demonstrated and measurable experience in strategic planning, team building, and financial stewardship.

• Strong expertise in quality data metrics and the ability to translate data to actionable items.

• Excellent written and verbal communication skills, computer proficiency, team building, relationship management, and conflict negotiation (problem-solving) skills.

• Comprehensive knowledge and understanding of clinical effectiveness, evidence-based medicine, high reliability, and quality improvement tools and principles.

• Effective communication and interpersonal skills, with the ability to collaborate and influence stakeholders at various levels.

• Proficiency in utilizing healthcare information systems and data analytics tools.

• A commitment to fostering a cultural of continuous improvement, patient safety, and accountability.

Cultural Responsiveness

• Demonstrate a commitment to diversity, equity, and inclusion through continuous development, modeling inclusive behaviors, and proactively managing bias.

Other Knowledge, Skills, and Abilities Preferred:

• Peer reviewed publications and/or professional presentations relevant to quality and safety strongly preferred.

Working Conditions:

• Periods of high stress and fluctuating workloads may occur

• General office environment

• Required to car travel to off-site locations, occasionally in adverse weather conditions

• Long-distance or air travel as needed - not to exceed 10% travel

• May have periods of constant interruptions

Physical Requirements:

Physical Demands: Lifting/ Carrying (0-50 lbs.), Push/ Pull (0-50 lbs.), Stoop, Kneel, Squat, Balance, Bending

Work Position: Sitting, Walking, Standing

Additional Physical Requirements/ Hazards

Physical Requirements: Manual dexterity (eye/hand coordination), Hear alarms/telephone/tape recorder, Reach above shoulder, Repetitive arm/hand movements, Finger Dexterity, Color Vision, Acuity - near, Acuity - far

Hazards: Depth perception

Mental/Sensory -Emotional

Mental / Sensory: Strong Recall, Reasoning, Problem Solving, Hearing, Speak Clearly, Write Legibly, Reading, Logical Thinking

Emotional: Fast pace environment, Steady Pace, Able to Handle Multiple Priorities, Frequent and Intense Customer Interactions, Noisy Environment, Able to Adapt to Frequent Change

EEO Employer/Disabled/Protected Veteran/41 CFR 60-1.4.