Vice President Quality Patient Experience

Midland Health•Midland, TX

About The Position

Reporting to the President/CEO, the Vice President – Quality Management & Patient Experience will develop and implement a comprehensive quality, patient safety and patient experience program across the system. The goal is to foster clinical excellence, promote innovation and ensure patient safety by participating in clinical initiatives that promote evidence-based practices. The Vice President - Quality Management & Patient Experience will serve as executive staff liaison for quality improvement, patient experience, infection control, occupational health, medical staff services, hospital accreditation, trauma and cultural diversity departments. The Vice President - Quality Management & Patient Experience will support the implementation and monitoring of programs and activities designed to ensure that the hospital incorporates methods to improve the safe administration of care while promoting a culture that promotes patient safety to be of upmost importance. Responsible for ensuring that the quality management and patient safety system conforms to DNV/ISO standards by serving as the Management Representative.

Requirements

A master’s degree in a healthcare field.
5-10 years of experience in a senior leadership position with a strong foundation in quality, patient safety and patient experience.
Moderate proficiency in Microsoft Office applications.

Nice To Haves

Cerner experience is a plus.

Responsibilities

Establish governance structures and processes to ensure adherence to workflows and policy.
Navigate political landscapes to address barriers and address goals.
Engage clinical leadership in determining relevant performance measures and benchmarks.
Develop quality metrics for ongoing professional practice evaluations (OPPE).
Design solutions to address opportunities based on benchmarking, goal comparison, data analysis and corrective actions.
Incorporate evidence-based practice into proposed interventions. Implement strategies to address barriers across the organization.
Evaluate the effectiveness of the organization’s quality improvement initiatives and adjust as required for ongoing success and sustained results.
Develop dashboards and scorecards incorporating metrics (national or payor benchmarks) tailored to strategic or operational goals.
Communicate the impact of quality initiatives on federal/state payment/reimbursement programs (Inpatient Quality Reporting (IQR) program, Outpatient Quality Reporting (OQR) program, HAC Reduction program, VBP, Hospital Readmission Reduction (HRR) program, eQCM submission, RAC requirements and state cancer registry).
Evaluate voluntary external standards to advise the organization on whether these advance or impede the achievement of strategic goals. Examples include service line awards/certifications, Leapfrog and clinical registries). Current clinical registries include National Surgical Quality Improvement Project (NSQIP), Vascular Quality Improvement (VQI), American Joint Replacement Registry (AJRR) hips and knees, American Academy of Orthopedic Surgeons Registry (AAOS) shoulder and spine, and Society of Thoracic Surgeons Registry (STS). This is a dynamic list that will most likely change from time to time.
Conduct an annual culture of patient safety survey.
Ensure that processes are created to address gaps identified in the survey findings.
Maintain an electronic database whereby safety risks or events can be reported.
Apply root cause analysis (RCA), FMEA, surveillance activities and risk assessments to identify and evaluate patient safety risks.
Utilize findings from RCA, gap analysis, surveys and audits to design appropriate interventions.
Assist in reviewing medical record documentation for appropriateness of care and advise leadership accordingly.
Ensure compliance with the Medicare grievance CoP standards.
Provide leadership and guidance in the development and implementation of the Quality Management/Patient Safety System that involves all departments and services, focuses on indicators related to improved health outcomes and reduction of medical errors.
Intervene when necessary, involving senior leadership, to hold owners accountable for actions and established deadlines.
Provide analysis and interpretive guidance of federal and state regulations/standards.
Serve a subject matter expert by acting as the DNV Quality Management Representative for the organization.
Establish a continuous accreditation survey readiness process that incorporates accountability and participation by all levels of staff.
Provide oversight for presurvey, onsite survey, and post-survey accreditation activities.
Oversee the coordination, submission and monitoring of corrective action plans associated with accreditation and/or certification of service lines.
Ensure that an electronic document management system is maintained.
Assess policies to ensure that they reflect applicable regulations/standards.
Oversight and responsibility for enhancing and continually improving the overall experience of patients and families throughout Midland Health.
Create a culture of passion and commitment for exemplary patient experience.
Present data to all levels of the organization, from executive staff to front line staff.
Understand national and regional benchmarks. Coordinate external benchmarking projects and collaborative opportunities with external agencies.
Drive organizational improvement strategies. Measure, monitor, and assess the outcomes of all initiatives.
Collaborate with Midland Health leaders to achieve goals exceeding national benchmarks.