AVP Quality and Safety
Wellstar Health Systems

Facility: Cobb Hospital
Job Summary:

The Assistant Vice President (AVP) Quality reports to the hospital's Vice President, Medical Affairs. As a member of the leadership team, this individual is responsible for developing a vision and executable plan to attain world class quality and safety processes and procedures across the hospital and all hospital outpatient departments. Bringing patient and clinical quality expertise, the AVP will partner to identify opportunities for short and long term impact on quality and safety outcomes.
The AVP Quality is responsible for developing, planning and implementation of key clinical quality, safety and accreditation initiatives as defined by executive and physician leadership. This role will serve as a champion for quality, accreditation and Safety First programs, creating a culture of individual accountability and support. The AVP Quality will supervise the key processes in support of performance improvement, including medical staff PI committees and peer review, PI registries, and Lean PI implementation. In addition, this individual will work to effectively integrate functions and coordinate collaboration across the care continuum. The AVP of Quality will be accountable to ensure successful development and deployment of the WellStar's Quality and Safety strategy to all care sites and services lines under the hospital's license.
The AVP will work collaboratively with Hospital and System Quality and other clinical leaders as a resource and advisor, proactively analyzing, seeking out opportunities to improve operational, clinical, quality, and patient satisfaction enhancements. This leader will partner with external organizations to ensure regulatory compliance and best practice efforts.
The individual in this role will identify opportunities to optimize performance, build internal competencies and create a more rigorous approach to quality and safety throughout the enterprise, bringing a strong focus on accountability and appropriate use of resources. The establishment of a culture of ownership, responsibility, and accountability will be a foundational characteristic for this role. The AVP maintains strong positive relationships with team members, medical staff, senior leaders, and patients.
The AVP Quality participates as an active part of WellStar's leadership team in developing and implementing Hospital and System strategic quality plans and initiatives. This leader 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:

Results-Oriented Leadership of Quality Services
* Oversight for the development and implementation of the hospitals Performance Improvement Plan in accordance with regulatory requirements, in response to hospital improvement opportunities, and in coordination with the WellStar strategic plan and goals.
* Assists hospital departments in the development of their Quality Assurance Performance Improvement (QAPI) goals and action plans. Ensures departments provide routine reporting of progress.
* Conducts an annual assessment of the hospital PI Plan, providing a written report, and revising the plan as indicated.
* Collaborates with Hospital and System Leadership to align priorities and resources with hospital and system goals.
* Plan and implement and provide appropriate support for key clinical quality and safety initiatives
* Provide strategic direction and guidance on quality, safety and accreditation to operational leaders and timelines for new guidelines, regulations and processes
* Effectively utilizes and collaborates with the corporate Enterprise Intelligence and Public Reporting teams on the analysis, interpretation and communication of publicly reported quality measures
* Monitors clinical and performance outcomes via benchmark analysis and facilitates accountability via defined expectations and goals
* Develops area-specific strategic plans and works with managers to facilitate goal achievement
* Serves as hospital Patient Safety Officer, providing oversight of comprehensive patient safety program.
* Oversight for processes related to sentinel events, sentinel event alerts; FMEAs, NPSGs, and other priorities are implemented and monitored for effectiveness. Assures appropriate parties are involved in the review process and documentation and follow up is through and timely.
* LEAN- Oversight of the local LEAN transformation office and functions in close coordination with the System LEAN transformation office.
* Facilitates standardization and prioritization of operations to achieve hospital objectives while assuring continuous quality improvement and outcome excellence
* Interfaces with the Patient Experience team and Customer Service to identify and respond to quality / safety issues and their impact on the overall patient experience
* Interfaces with Human Resources and Employee Health to maximize team member safety.

Oversees the Continuous Survey Readiness Program by:
* Coordinates and facilitates survey activity including, but not limited to Joint Commission accreditation, CMS and State regulatory surveys. Provides consultative support for disease specific certification surveys.
* Oversight and Coordination in the use of tracer and mock surveys conducted within the hospital. Assures that they are conducted as required with timely reporting and support to hospital departments and managers. Participates in system-wide mock survey activities.
* Routinely reviews regulatory and accreditation standards. Supports Functional Area Leaders to ensure compliance by providing education, and assisting with proactive identification of non-compliant practices.
* Identifies high risk areas for regulatory compliance and facilitates education and process improvement efforts to create alignment and compliance
* Accountable for ensuring that action plans are developed to address deficiencies identified by regulatory agencies are fully executed by required deadlines and that actions are monitored for effectiveness and sustained improvement.
* Communicates Survey Readiness success and potential barriers with Administrative, Hospital, and Physician Leaders.

Oversees Daily Operations of the Department by:
* Oversight and direction of HR functions for the department which includes interviewing, hiring and orienting staff in collaboration with managers. Responsible for team building across departments.
* Oversight for completing performance evaluations in a timely manner.
* Oversight for time keeping for teams & for responsible for managing schedules/time and attendance.
* Conducting regular meetings with direct reports and supporting individual developmental goals.
* Develops operating and capital budgets in coordination with hospital and system initiatives; monitors to ensure variance analysis and resolution
* Implementing new or revised programs of the department.

Directs and Coordinates the Medical Staff Quality Review, Hospital Quality and Patient Safety Committees by:
* Supervises the processes for data abstraction, review and management for Medical Staff Quality Review, Peer Review, Process Improvement, and registries
* Coordinating Committee activities.
* Ensuring that action plans are developed and executed for prioritized areas of opportunity.
* Directing the work of the Committee and implementation of improvements.
* Maintaining Committee documents.
* Oversight for maintenance of confidentiality of all related information.

Performs other duties as assigned

Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

Bachelor's Degree in Nursing, Healthcare Quality, Business, Public Health, or a related field Required or
Master's Degree in Nursing, Healthcare Quality, Business, Public Health, or a related field. Required or

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

All certifications are required upon hire unless otherwise stated.

• Cert Prof Healthcare Quality

Additional License(s) and Certification(s):

Required Minimum Experience:

Minimum 12 years experience in healthcare including five (5) years in a quality management setting required. Required and
Seven (7) to ten (10) years of progressive clinical and/or quality leadership experience, with a minimum of five (5) years in management roles is required. Required and
Minimum 2 years in program development Required and
Lean and Project Management experience Preferred and
Previous experience with proven leadership in regulatory and accreditation survey readiness, quality improvement and patient safety in a large acute care system or facility required, including demonstrated ability in interpreting quality metrics to lead actionable change. Required and
Strong experience with patient safety event management, including conducting root cause analysis and facilitating creation of effective, timely action plans Required and
Experience managing workflow in event management systems (e,g, RL Solutions, Midas, Marsh) with the ablity to interpret and utilize trended event data to improve safety. Required and
Experience leading improvement work using a scientific methodology Required and
Lean management system and Lean Production System methodology Preferred and
Experience coordinating with and reporting data to a Patient Safety Organization (PSO) Preferred and
Experience managing and/or monitoring infection prevention functions Preferred

Required Minimum Skills:

Strong interpersonal skills with the ability to communicate and work with all levels of healthcare providers including physicians.
Ability to perform duties and responsibilities promptly and consistently with little direct supervision.
Ability to execute a plan and use project management methodology. Ability to plan and direct activities of others and objectively appraise and analyze their job performance.
Ability to work collaboratively with other departments within and outside the Hospital.
Ability to judge the appropriate action in response to changes, circumstances, or problems.
Experience in data collection, analysis and project management required.
Strong computer skills required.
Excellent communication, presentation and organization skills required.
Working knowledge of data collection methodologies, interpretation/analysis and decision support databases.

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