AVP Quality, Regulatory and Patient Safety

Capital Health•Hopewell, NJ

3d•Onsite

About The Position

Provides operational and strategic leadership for the implementation, coordination, and oversight of quality improvement, regulatory compliance, accreditation readiness, and patient safety activities across Capital Health. Translates organizational quality and safety priorities into standardized processes, measurable improvement plans, and sustained operational performance. The role partners closely with executive, physician, nursing, clinical, and administrative leaders to identify performance gaps, implement evidence based improvement strategies, and support the delivery of safe, effective, patient-centered care. Provides leadership to teams responsible for advancing organizational performance and a culture of high reliability and continuous improvement.

Requirements

Master’s degree in healthcare administration, nursing, business administration, or related field required.
Seven years or more of progressive hospital or healthcare operational management, including a focus on healthcare quality, patient safety, regulatory compliance, and performance improvement.
Clinical licensure as applicable
Comprehensive knowledge of healthcare regulations, clinical governance, and accreditation processes.
Strong leadership and team-building skills, with demonstrated ability to lead, collaborate, and build consensus across diverse professional teams, fostering a culture of accountability and high performance.
Expertise in quality improvement methodologies and data analytics for clinical performance tracking.
Excellent communication and presentation skills, with the ability to effectively convey complex information to diverse audiences.
Strategic thinker with strong decision-making abilities and a focus on continuous improvement.
Financial acumen, with experience managing budgets and aligning clinical performance with financial objectives.

Responsibilities

Operationalizes organizational quality priorities and leads implementation of quality improvement initiatives across the health system, ensuring alignment with strategic goals and regulatory requirements.
Oversees systems for tracking, reporting, and analyzing clinical performance metrics.
Partners with data analytics and operational leaders to identify performance gaps, establish improvement targets, and monitor sustained results.
Ensures timely and accurate external quality reporting, including applicable CMS, Leapfrog, and other required or organizationally selected reporting programs.
Monitors key performance indicators and provides performance reports, trends, risks, and recommended actions to executive leadership and applicable quality committees.
Supports Board Quality committee activities and prepares or coordinates quality and safety reporting as assigned.
Interprets regulatory and accreditation requirements and partners with operational leaders to translate requirements in compliant, sustainable practices.
Coordinates organizational survey preparedness, tracer activities, corrective action plans, and follow up activities related to accreditation and regulatory findings.
Escalates significant regulatory risks, compliance gaps, and barriers to the appropriate executive leader and ensures action plans are developed, monitored, and closed.
Provides leadership for the patient safety program and supports the designated Patient Safety Officer responsibilities as assigned by the organization.
Oversees processes for occurrence reporting, event review, trend identification, and escalation of significant safety concerns.
Partners with clinical and operational leaders in the review of series events and supports the development, implementation, and monitoring of corrective and preventative actions.
Advances High Reliability Organization (HRO) principles and safety culture practices in partnership with system leadership.
Promotes a just, learning focused culture that supports transparent reporting, shared accountability, and sustained improvement.
Oversees patient experience performance metrics and trends, including applicable survey results, complaints, and grievances.
Collaborates with the Director of Patient Experience to strengthen communication, responsiveness, service recovery and patient centered care practices across the continuum.
Identifies recurring themes and opportunities from patient feedback and ensures significant concerns, barriers and trends are escalated to appropriate leadership and incorporated into organizational quality and safety priorities.
Provides direct leadership and performance management for assigned quality, regulatory and patient safety leaders and staff.
Partners with Vice Presidents, Assistant Vice President, Directors, Managers, physicians, nursing leaders, and other stakeholders to ensure quality safety, and regulatory readiness are integrated into daily operations.
Works closely with operational leaders to establish clear ownership for improvement plans, timelines, measures of success, and sustainment strategies.
Supports development of annual departmental goals, resources needed, and budgets and ensures responsible stewardship of assigned resources.