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Vice President, Quality

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Job ID REQ_154203 FACILITY St Lawrence Health LOCATION Potsdam, New York

Position Summary:
The VP of Quality, delivers and coordinates quality improvement and compliance programs  aimed at developing the culture and competencies necessary to achieve strategic business objectives, continually improve effectiveness and efficiency and continually evolve to meet new business challenges. 

STATUS: Full Time


DEPARTMENT: Quality Management

SCHEDULE: 8 hours variable


This role is accountable for developing and overseeing comprehensive quality assessment and performance improvement (QAPI) systems and fostering a culture of continuous improvement; developing and overseeing systems that ensure compliance with established standards of practice, applicable state and federal laws and regulations and DNV accreditation standards; and advising leadership and Boards on performance measurements, risk assessments, and initiatives related to QAPI and compliance.

1. (20%) Develop and oversee comprehensive quality assessment and performance improvement (QAPI) systems and foster a culture of continuous improvement. Supports all efforts of the QAPI program, actively participates in the QAPI Committee, and chairs QAPI staff subcommittees.
2. (20%) Promotes delivery of high quality care through leadership and development of organizational quality and patient safety goals. In collaboration with the QAPI Committee, regularly assesses performance and risks, and develops and updates a data-driven QAPI plan at least annually. Educates and trains the leadership, Boards, and staff as to the QAPI program and their respective responsibilities in carrying out the program.
3. (15%) Provides statistical analysis, work process analysis, project scheduling, root cause analysis, and benchmarking expertise for quality improvement initiatives. Ensures appropriate systems are in place to track and report on all core measures and performance improvement initiatives; facilitates ongoing monitoring, evaluation, and reporting of customer satisfaction and patient service incidents; and interfaces with patients and families to ensure that care is consistent with their expectations.
4. (15%) Coordinates and/ or conducts ongoing Performance Improvement Projects on needs identified through data monitoring and analysis and satisfaction survey results. Partners with patient care leadership and staff to support quality projects and other initiatives.
5. (15%) Initiates periodic and ongoing internal audits for the DNV and ISO standards. Aggregates and analyzes findings; facilitates education or process change as needed; and leads periodic performance review and preparation efforts for accreditation surveys. Develop and oversee systems that ensure compliance with established standards of practice, applicable state and federal laws and regulations, and DNV accreditation standards.
6. (15%) Oversee investigations of all non-conformances.

Performs other duties as assigned

Minimum Qualifications:

• Master’s Degree in Nursing or Healthcare Administration.
• 10 years’ experience in performance improvement in a  healthcare setting; 7 to 10 years’ experience  in leadership and administrative supervision;  and 7 to 10 years’ experience in compliance and quality control, quality improvement, and quality assurance.
• High level of organizational skills to manage projects, timetables, and implementations
• Advanced interpersonal skills to manage, direct, and coordinate activities.
• Excellent written and oral communication skills
• Strong analytical ability to develop and interpret application of best practices and outcome metrics
• Ability to influence and negotiate individual and group decision making
• Strong leadership and management skills
• Demonstrated skills and experience in methods of improvement, theories of change, and current concepts of team building
• Must possess technical knowledge of metric development, data collection, and analysis
• Proficient in Microsoft Excel, Word, PowerPoint, Visio, and other desktop applications
• Knowledge of NYPORTS preferred

Required Licensure/Certification Skills:

  • For those with a BSN; valid NYS Registered Nurse License.
  • Preferred: Certified Professional HealthCare Quality (CPHQ), ASQ Six     Sigma Green Belt or higher.

Rochester Regional Health System is an Equal Opportunity / Affirmative Action Employer. Minority/Female/Disability/Veteran.

PHYSICAL REQUIREMENTS S - Sedentary Work - Exerting up to 10 pounds of force occasionally Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.
Rochester Regional Health is an Equal Opportunity / Affirmative Action Employer. Minority/Female/Disability/Veteran
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