Reporting to the Chief Quality and Clinical Informatics Officer, the AVP of Quality is responsible for the clinical quality and patient safety outcomes of LRH’s patients within the hospital, the ambulatory outpatient division, and expanding into the community and post-discharge. As a key leader of the Quality Division, this role is accountable for leading an effective quality program focused on continuous improvement, continual readiness, quality reporting and measures, and a culture of high reliability and safety. Responsible for population health objectives and managing the efforts to move LRH toward a value-based payment environment, and for developing population health capabilities to support system strategies that will improve the health of the Lakeland community. Direct reports to this position include the Director of Clinical Quality & Performance Improvement and the Director of Strategic Quality Performance. The team also includes the Manager of Accreditation, and the Manager of Quality & Population Health, and a total staff of approximately 23 individuals.
Primary Responsibilities
- People at the Heart of All We Do
- Communicates appropriately with patients, families, team members, and our community in a manner that treasures all people as uniquely created.
- Ensures patients and families have the best possible experiences across the continuum of care.
- Fosters an inclusive and engaged environment through teamwork and collaboration.
- Safety and Performance Improvement
- Behaves in a mindful manner focused on self, patient, visitor, and team safety.
- Demonstrates accountability and commitment to quality work.
- Participates actively in process improvement and adoption of standard work.
- Stewardship
- Demonstrates responsible use of LRH’s resources including people, finances, equipment and facilities.
- Knows and adheres to organizational and department policies and procedures.
- Standard Work
- Identifies ideas, actions, and processes to improve quality, reduce risk, and improve patient safety. Incorporates quality and patient safety into organizational processes and systems. Reviews the quality metrics and measurement categories, analyzes findings, plans improvement actions, and makes recommendations for improvement efforts. Leads the advancement of a successful culture of patient safety and quality.
- Develops and maintains effective working relationships among administrative leaders and medical staff necessary to carry out the goals and objectives for the organizations Quality and Safety program.
- Leads the Infection Prevention department, overseeing the organization’s infection prevention program, including the design, implementation and monitoring of the effectiveness of the program.
- Leads the Clinical Quality Consultant team to implement quality improvement action plans and drive accountability within the Medical Center.
- Oversees the Medical Staff Quality Function, serving as a key organizer and participant in the Quality Improvement Committee of the Medical Staff. Ensures provider quality monitoring is completed and applied to support credentialing efforts, but more importantly drives performance improvement by physicians.
- Designs and executes the organization’s Continual Readiness program for Joint Commission, ensuring the organization is prepared and overseeing any regulatory accreditation visits.
- Manages the organization’s readmission program, designing care management efforts to effectively reduce unnecessary readmissions to the medical center to achieve desired outcomes within the CMS HRRP program.
- Leads or is a key participant in operational groups that address activities related to value-based contracts.
- Partners with health system management to help lead the Quality strategies and measurements in our growing Ambulatory division for programs such as the Merit-Based Incentive Payment System (MIPS).
- Leads the continuous improvement with the CMS value-based and pay-for-performance programs, quality core measures, patient safety measures, hospital readmissions, hospital acquired conditions, health equity, the Merit-Based Incentive Payment System (MIPS), and the quality rating measurements (e.g. CMS Star Ratings, Leapfrog, Healthgrades).
- Leadership
- Demonstrates accountability for strategic programs and service delivery within all areas of responsibility to support achievement of organizational priorities.
- Coaches leaders to support career growth and promotion and ability to lead and influence key stakeholders.
- Engages direct leadership team to leverage talent and embrace, sponsor and develop diversity of talent and capabilities.
- Directs and participates in direct leadership team development, performance management and engagement.
- Leads change by communicating a clear vision, influencing and motivating others, and encouraging leaders to take on new opportunities.
- Assists Executive Leadership in the design of a healthy and safe culture that advances organizational, team and individual performance.
Required Qualifications & Experience
- Master’s prepared (required)
- Certified Professional in Healthcare Quality (preferred)
- 10+ years of leadership experience within a healthcare system.
- 5+ years of experience leading quality, performance improvement, and patient safety related functions.
- 5+ years of experience working directly with hospital department managers and staff members (and not just working in a corporate office with minimal involvement at the hospital department level).
- 5+ years of experience assessing, formulating, and implementing all aspects of the Quality/Performance Improvement program (and not just using a program established from a corporate office).
- Preferred: 5+ years of experience as the administrative head of quality for a health system or hospital with the primary and direct responsibility for all quality outcomes and results (and not just a field level position within a multi-site corporate system).