JOB DESCRIPTION:

The Vice President of Quality and Patient Safety provides oversight, development and administration of systemwide quality management, performance improvement, and regulatory compliance activities, to achieve Emory Healthcare (EHC) goal of clinical excellence. Supports the EHC Chief Quality Officer (CQO) with development and implementation of quality improvement activities.  Serves as the system lead for infection prevention, patient safety, performance Improvement/process improvement and clinical innovation Oversees data analysis for support of physician peer review and professional performance evaluations, quality education, and quality management of affiliate hospitals.

Primary Duties and Responsibilities:

• Collaborates with the EHC CQO to execute the EHC QPS plan and EHC strategic priorities by developing and by using Lean principles and other approaches to improve clinical and process outcomes related to patient safety, infection prevention, and other key quality performance metrics that are used to determine incentive and potential penalties as measured by CMS, private payers, and public benchmarking of EHC performance.
• Develops, plans, coordinates, and implements strategic and day-to-day quality (clinical improvement) programs across Emory Healthcare.
• Coordinates and oversee all survey activities, policy management, and regulatory reporting to ensure that full accreditation, certification, and licensure are maintained in all facilities.
• Collaborates with local hospital operating unit leaders and Emory University academic departments to ensure integration of clinical quality management, regulatory compliance, patient safety, and risk management efforts across EHC.
• Manages the Quality & Patient Safety staff in adherence with EHC policies and standards with the responsibility for hiring, development, coaching, mentoring and performance management of staff.
• Supports the Patient Safety Quality Committee of the Board of Directors of the hospitals of EHC
• Participate in organizational committees at both the hospital and system committees as assigned or needed.

Quality: Anticipates national trends and initiatives in performance improvement, clinical quality, health care informatics, and the use of clinical technology for improvement efforts. Develops and implements programs to ensure EHC and its entities are well positioned for local, state and national clinical regulatory programs, value-based purchasing methodologies, and comparison ratings.

Regulatory Accreditation and Certification: Provides leadership regarding regulatory standards and compliance: regulatory body hospital wide review/surveys (the Joint Commission, DCH, etc.) as well as surveys for Stroke and Bariatric hospital certifications. Monitors and promotes actions to achieve compliance with all relevant city, state and federal laws, government regulations, accrediting agency standards, and health system policies. Ensures compliance with all regulatory requirements regarding practices policies and monitoring functions. Interprets, educates and assures hospital compliance with rules/regulations of The Joint Commission, CMS and any other regulatory agency with regards to quality of care and patient safety.

Policy Management: Provides oversight and administrative direction for the system-wide management structure and policy repository tool; maintain and lead regular reviews and updates of all EHC policies and procedures.

Infection Prevention: Provides oversight of the Infection Prevention program and efforts.

Patient Safety: Leads the patient safety efforts across EHC in partnership with the Patient Safety Officer to become a high reliability organization. Implements and maintains patient safety event reporting system, RCAs, ACAs, FMEAs, and state reporting for review of all reported patient safety events. Fosters an environment that supports a Just Culture, in which staff members feel safe to report errors and participate in the analysis and mitigation of errors.

Quality Data Strategy and Program Reporting: Provides leadership and oversight regarding the abstraction, analysis and management of regulatory and quality improvement data and appropriate reporting to regulatory bodies and registries. Provides leadership of clinical quality data strategy for improvements in collaboration with data analytics team and information technology team.

Ongoing Professional Performance Evaluations and Peer Review Analysis: Maintains physician credentialing, recredentialing, and to meet regulatory performance evaluations.

Quality Education: Directs and oversees efforts to provide quality improvement education to EHC staff and clinicians.

MINIMUM QUALIFICATIONS:

A medical degree (MD or DO) or Master's degree in Nursing, Public Health, Healthcare Administration or a related field, along with ten (10) years of progressive experience in related healthcare and/or quality related role required. Certified Professional in Healthcare Quality (CPHQ) and/or Lean/Six Sigma Black Belt designation preferred.

Specific experience with the design and implementation of quality, performance improvement and patient safety efforts in a complex health system required. Leadership experience in a complex, highly matrixed, academic health system for at least five (5) years at the corporate or health system level strongly preferred.

Supporting a diverse, equitable and inclusive culture.  Emory Healthcare (EHC) is dedicated to providing equal opportunities and access to all individuals regardless of race, color, religion, ethnic or national origin, gender, genetic information, age, disability, sexual orientation, gender identity, gender expression and/or veteran's status. EHC does not discriminate on the basis of any factor stated above or prohibited under applicable law. EHC respects, values, and celebrates the unique perspectives and backgrounds of all individuals. EHC aspires to create an environment of collaboration and true belonging for all our patients and team members.  Emory Healthcare (EHC) is committed to achieving a diverse workforce through equal opportunity and nondiscrimination policy in all aspects of employment including recruitment, hiring, promotions, transfers, discipline, terminations, wage and salary administration, benefits, and training.

ACCOMMODATIONS: EHC will provide reasonable accommodations to qualified individuals with disabilities upon request. To request this document in an alternate format or to request a reasonable accommodation, please contact the Office of Diversity, Equity, and Inclusion.” 

ENVIRONMENTAL FACTORS: Factors affecting environment conditions may vary depending on the assigned work area and tasks. Environmental exposures include, but are not limited to: Blood-borne pathogen exposure; Bio-hazardous waste Chemicals/gases/fumes/vapors; Communicable diseases; Electrical shock; Floor Surfaces; Hot/Cold Temperatures; Indoor/Outdoor conditions; Latex; Lighting; Patient care/handling injuries; Radiation; Shift work; Travel may be required; Use of personal protective equipment, including respirators; environmental conditions may vary depending on assigned work area and work tasks.