Vice President - Chief Quality Officer

Thedacare • Neenah, WI

23d

About The Position

The Vice President, Chief Quality Officer is a member of the ThedaCare leadership team and provides leadership for achieving the ThedaCare mission, vision, and strategy across the entire health system in accountable care, employed physician group, acute care and all other aspects of the continuum of care. The position will report to the Chief Clinical Officer of ThedaCare. Is responsible for the development and implementation of quality, patient and team member safety, and clinical process improvement to attain high reliability in delivery of patient care. Provides leadership for ThedaCare’s strategic direction for quality, infection prevention, medication safety, safety services (including security and communication center), employee health, and translation services.

This role will foster collaboration across all ThedaCare campuses and divisions to improve the health of the communities we serve. The position will partner with divisional leaders and external constituents to develop and implement solutions to ensure quality of care and cost-effective services throughout the service area to deliver best outcomes for ThedaCare patients and families. Exercises appropriate authority and accountability for the administration and long range planning of ThedaCare’s population health strategy through exceptional quality, infection prevention, medication safety, and safety services, and maintaining effective team member, medical staff, and community relationships.

Requirements

• An MD/DO with board certification in an accredited ABMS/ABOMS specialty or a Master’s Degree in Nursing or equivalent
• 5 years or more of progressive leadership in healthcare including performance improvement experience, quality management experience, and regulatory compliance knowledge concerning The Joint Commission and CMS standards
• Experience with development of people and teams
• Knowledge of clinical measurement and data management in a large complex healthcare organization
• Knowledge and utilization of improvement tools and leadership of improvement effort
• Knowledge of health care payer and regulatory authorities
• Ability to move freely (standing, stooping, walking, bending, pushing, and pulling) and lift up to a maximum of twenty-five (25) pounds without assistance
• Job classification is not exposed to blood borne pathogens (blood or bodily fluids) while performing job duties

Responsibilities

• Translates ThedaCare’s organizational strategies, tactics, leadership, management, and collaboration into the strategic and operational direction for quality performance and patient safety including quality, infection prevention, regulatory readiness, care management, UR/UM, and CDI.
• Ensures ThedaCare’s participation in appropriate community, state, and national leadership organizations. Fosters and maintains collaborative relationships with external agencies, payers, and stakeholders related to quality, safety, and regulatory programs.
• Ensures identification and implementation of performance and patient safety strategies to further integrate and promote operational change and improvement functionally and clinically throughout ThedaCare.
• Proactively educates and communicates safety, performance improvement, regulatory, compliance issues, and new statutes/guidelines and activities throughout ThedaCare.
• Oversees the development of ThedaCare and facility policies, procedures, and standard work related to clinical performance improvement and safety.
• Oversees the reporting requirements and reporting of events internally and externally as required by regulatory agencies in collaboration with process owners and risk management. Communicates quality and safety outcomes to ThedaCare leadership in a timely manner.
• Maintains current knowledge of national and state regulatory issues related to quality improvement and measurement requirements, and provides leadership with regular updates of proposed and finalized changes.
• Chairs, participates, and facilitates ThedaCare and facility-specific committees, PDSAs, and teams. Provides support for all system safety and quality committees.
• Provides strategic direction and oversight of regulatory performance improvement to maintain high levels of institutional readiness, meeting and exceeding state and national regulatory requirements.
• Utilizes, integrates, and interprets data to assist ThedaCare in its improvement efforts, and promotes optimal patient outcomes. Works collaboratively with executive leaders to develop strategic quality initiatives.
• Ensures responsibility for the ThedaCare occurrence reporting system, analyzes and reports trends, and identifies appropriate interventions to reduce risk and liability to ThedaCare.
• Leads organizational performance efforts for The Joint Commission (TJC) core quality measures, COP, regulatory, and all other accrediting and regulatory agencies. Ensures compliance with The Joint Commission, and that all legal, regulatory, and accrediting agency requirements are met.
• Develops and implements quality educational programs for team members, medical staff, and board members on analysis of quality opportunities, root cause analysis, and implementation of countermeasures for safety and improvement.
• Participates in and provides leadership for organizational disaster preparedness and patient safety initiatives.
• Provides leadership, administrative and management support, strategic planning, and overall direction and guidance on program development, projects, and collaboratives that support clinical quality and clinical safety performance improvement.
• Responsible for working collaboratively with leadership in setting direction and strategic planning to develop, implement, and monitor action plans to achieve overall Quality Management program success and the provision of safe, highly reliable clinical outcomes.
• Develops annual goals and objectives for the Quality Management program in alignment with overall system clinical and operational goals and strategies to meet and exceed established program objectives utilizing external benchmarking.
• Leads the process for evaluating compliance of the quality program against internal and external requirements.
• Collaborates with Decision Resources and effectively utilizes analytics to review and ensure the visibility of quality performance for the organization.
• Collaborates with contract management and executive leaders to incorporate quality metrics into internal and external contract and incentive management that align with the achievement of organizational goals and regulatory compliance.
• Directs and evaluates patient safety activities to include sentinel/high severity event review, root cause analysis and action planning, failure mode and effect analysis, and national patient safety goal review and action planning.
• Supports and ensures the deployment and evaluation of facility level quality assurance/quality improvement annual plans that meet all elements of regulatory compliance.
• Prepares and presents reports to executive leadership, the Board of Directors, providers, leadership, and team members in both written and oral formats

Benefits

• Lifestyle Engagement
• e.g. health coaches, relaxation rooms, health focused apps (Wonder, Ripple), mental health support
• Access & Affordability
• e.g. minimal or zero copays, team member cost sharing premiums, daycare

What This Job Offers

• Job Type: Full-time
• Career Level: Executive
• Number of Employees: 5,001-10,000 employees