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Serves as focal point in addressing the evolution of the organization’s quality, safety performance, patient safety and regulatory compliance. Exceeds the standards and quality expectations of patients, the Board of Directors, regulatory bodies, and payors.
MINIMUM QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Terminal degree (MD, Pharm.D., DNP) in healthcare field or Masters Degree (Public Health, Healthcare Administration, Business)
2. Licensure in practice area (medicine, pharmacy, nursing, etc), if applicable
EXPERIENCE:
1. Five years of experience in healthcare setting at an academic medical center or 250+ bed facility
2. Three years in management role
3. Quality and patient safety experience at an academic medical center or 250+ bed facility
PREFERRED QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Certification in healthcare quality is preferred (CHPQ)
EXPERIENCE:
1. Minimum comparable experience requires at least 250 beds OR at academic medical center
CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.
1. Ensures compliance with The Joint Commission, Office of Healthcare Facilities and Licensing (OHFLAC) and other regulatory bodies; assists departments with resources to maintain regulatory compliance.
2. Responsible for monitoring of patient safety through employee reported events, patient reported concerns, and associated quality metrics, including but not limited to falls, pressure sores, and infections. Includes working with Medical Executive Committee to report issues of quality.
3. Responsible for ensuring quality is maintained via house-wide measures and direct oversight of root cause analysis and reporting to ensure timely completion and implementation of changes and ongoing accordance with changes identified.
4. Work with signature programs on the development of service line indicators, scorecards, oversight of quality measurement, development of clinical pathways and practice guidelines.
5. Initiate mechanism to ensure proper validation procedures are developed and followed.
6. As the AVP, responsibility for leading directors and staff, including hiring, recruitment, retention, staffing, evaluations, disciplines, and evaluating effectiveness of team. Develops departmental budget to address departmental needs, including evaluating staffing patterns and monitoring budget reports.
7. Strategically develops individual department goals and improvement plans with an objective that these can be replicated and deployed to other system hospitals. Develops and maintains policies related to quality and safety and quality assurance standards to continually push towards improvement.
8. Works with HIM to identify opportunities for improvement and works actively to advance coding and documentation practices.
9. Ensures adherence with state required reporting and surveillance of infections, overseeing infection control and prevention program and ensuring inpatient and ambulatory leadership adheres to defined principles of program.
10. Provides leadership and oversight of quality programs at all WVUH and subsidiary sites.
11. Represents quality departments in system level discussions including affinity groups and new program development as well as in purchasing decisions through active participation in RFP processes.
12. Actively works to engage bedside providers including nursing staff and medical residents in quality and patient safety.
13. Oversees the administration of the annual Comprehensive Unit Based Safety Program and survey, evaluates results, and recommends action plans.
14. Identifies and implements unique and innovative initiatives aimed at improving clinical quality and patient safety. Recognizes potential barriers to implementation and develops a roll-out strategy with the assistance of the local staff and leadership.
15. Collaborates with departments to improve real-time reporting and efficient report outs of quality metrics to leaders.
16. Promotes customer satisfaction through implementation of activities to enhance Patient Experience at WVUH.
17. Assists in the development of metrics for provider ongoing professional practice evaluation (OPPE).
18. Collaborates with the Chief Quality Officer and other executives and engages with leaders and clinicians in a hands-on fashion to build quality, safety, efficiency, effectiveness, and a sense of shared accountability. Will work closely with department leaders to implement new strategies.
19. Strengthens the data and information capabilities of the organization and champions a data-driven environment.
20. Develops and leads educational opportunities in clinical quality and patient safety for healthcare workers.
21. Engages in scholarship related to clinical quality and/or patient safety and disseminates results through presentations and publications to augment the regional and national reputation of WVUH and WVU Medicine.
22. Performs other related tasks identified by the WVUH Executive Leadership Team.
PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
SKILLS AND ABILITIES:
1. Communicates clearly and effectively both orally and in writing
Additional Job Description:
Scheduled Weekly Hours:
40
Shift:
Exempt/Non-Exempt:
United States of America (Exempt)
Company:
WVUH West Virginia University Hospitals
Cost Center:
405 SYSTEM Quality Management
Address:
3040 University Ave
Morgantown
West Virginia
WVU Medicine is proud to be an Equal Opportunity employer. We value diversity among our workforce and invite applications from all qualified applicants regardless of race, ethnicity, culture, gender, sexual orientation, sexual identity, gender identity and expression, socioeconomic status, language, national origin, religious affiliation, spiritual practice, age, mental and physical ability/disability or Veteran status.
What We Do
The WVU Health System, which operates under the brand name WVU Medicine, is comprised of 22 member, managed, and affiliated hospitals in West Virginia, Maryland, Ohio, and Pennsylvania. It is West Virginia’s largest healthcare system and largest private employer with more than 2,500 licensed beds, 4,900 providers, approximately 30,000 employees, and more than $5 billion in total operating revenues.
It includes:
• J.W. Ruby Memorial Hospital in Morgantown (flagship), including WVU Medicine Children’s in Morgantown and Fairmont Medical Center in Fairmont;
• United Hospital Center in Bridgeport;
• Camden Clark Medical Center in Parkersburg;
• Berkeley Medical Center in Martinsburg;
• Barnesville Hospital in Barnesville, Ohio;
• Braxton County Memorial Hospital in Gassaway;
• Garrett Regional Medical Center in Oakland, Maryland;
• Harrison Community Hospital in Cadiz, Ohio;
• Jackson General Hospital in Ripley;
• Jefferson Medical Center in Ranson;
• Potomac Valley Hospital in Keyser;
• Princeton Community Hospital in Princeton, including The Behavioral Health Pavilion in Bluefield;
• Reynolds Memorial Hospital in Glen Dale;
• Saint Francis Hospital in Charleston;
• St. Joseph’s Hospital in Buckhannon;
• Summersville Regional Medical Center in Summersville;
• Thomas Memorial Hospital in South Charleston;
• Uniontown Hospital in Uniontown, Pennsylvania;
• Wetzel County Hospital in New Martinsville;
• Wheeling Hospital in Wheeling;
• And five institutes – the WVU Cancer Institute, the WVU Critical Care and Trauma Institute, the WVU Eye Institute, the WVU Heart and Vascular Institute, and the WVU Rockefeller Neuroscience Institute.
The WVU Health System also provides management services to Grant Memorial Hospital in Petersburg.
For more information, visit WVUMedicine.org
