AVP Quality Risk and Patient Safety RN
The AVP, for Quality, Risk, Patient Safety and MSO is responsible for the overall performance of Quality, Risk, Patient Safety, and the MSO at NL Mercy Hospital a including strategic development and implementation, successful execution of established objectives, and positive promotion of the services continuum from acute care through outpatient programming with linkage to community resources. The AVP is responsible for maintaining a culture of positive communication and cooperation between physicians, advance practice practitioners, nursing, and staff to ensure established objectives are achieved. The incumbent works in close partnership with the NL VP, Risk Management, and NL VP Chief Quality Officer to assist with the identification, evaluation, and assessment of new care delivery technology, developing recommendations on the impact of integration with existing workflows and systems. The incumbent supervises the following departments: Quality, Risk, and Patient Safety, the MSO. The AVP reports to the VP, Nursing and Patient Care Services with a Matrix reporting relationship to the Vice President, Senior Physician Executive for Mercy Hospital for Quality, Risk, Patient Safety,and MSO. The incumbent may be matrixed to other Vice Presidents/President of Mercy Hospital.
Is knowledgeable of hospital, department, and medical practice compliance requirements for federally funded healthcare programs (e.g. Medicare and Medicaid) regarding fraud, waste and abuse. Brings any questions or concerns regarding compliance to the immediate attention of administrative staff. Takes appropriate action on concerns reported by department staff related to compliance.
Purposefully conducts all aspects of the job in an ethical manner in support of the hospital's commitment to ethical behavior in all areas of personal and professional activity.
Collaborates with administrators, physicians, directors, managers and other providers to facilitate planning, implementation, and evaluation of the quality and patient strategic plan and initiatives.
Collaborates with leadership to create an operational plan consistent with the program's strategic plan.
Collaborates with leadership to develop unit/department-based goals and objectives that are in concert with the overall direction of the service line and the overall hospital strategic plan.
Guides priorities and focus of work for activities of the areas of responsibility and organization.
Links inpatient and outpatient plans to promote coordination of care across the continuum and to promote operational efficiency.
Facilitates/collaborates in the development of program and business plans to address newly identified patient care needs.
Develops annual and multiyear capital budgets.
Develops annual operational budget to support strategic plan.
Communicates and enforces the system-wide Corporate Compliance program for Mercy Hospital.
Reports any potential or real ethical, legal or regulatory violations to the Corporate Compliance Officer.
Encourages staff to report Corporate Compliance issues either directly or through the Mercy Compliance Line (may be anonymous).
Assists with investigations into alleged violations, and the development and implementation of disciplinary and/or corrective action as indicated.
Continually assesses the department for compliance with all federal, state, local and other regulatory (Joint Commission, OSHA, CMS etc.) requirements.
Completes annual staff training, ensuring staff understanding of participation in the above.
Oversees the daily operations of Quality, Risk and Patient Safety, and the MSO.
Makes recommendations to improve the productivity, quality and effective delivery of patient care services.
Develops and implements policies and procedures.
Achieves established productivity benchmarks for all areas of operations.
Responsible for the procurement and maintenance of equipment and supplies, staffing and training of employees and budgeting. Resource Management
Executes successfully the established plans and the services through measurement, monitoring, analysis, reporting, and adjusting the direction, allocation and utilization of available resources.
Collaborates with Physician Leadership to support program/practice changes to continually improve resource utilization.
Provides reports of budget analysis of direct report departments within the division to VP of Nursing and PCS monthly.
Advances Patient Care Standards
Models patient outcome focused care and customer centered philosophy in practice.
Interprets and addresses issues of patient care internally and externally (Administration, Medical Staff Committees).
Recognizes and addresses bioethical and legal issues that influence the delivery of patient care.
Assures compliance with all appropriate regulatory bodies for delivery of patient care.
Facilitates quality improvement activities and processes focusing on system Key Process Indicators (KPI’s) to drive results.
Participates in Board of Trustees Meetings to report on Quality and Patient Safety Outcomes.
Works collaboratively with system Leadership to achieve KPI’s locally as well as systemwide.
Reflects organizational, service line, and departmental goals in the performance improvement plan. The plan includes shared process improvement and outcome measures.
Integration of quality improvement activities is intentional and continuous. The various disciplines and medical staff share content areas and indicators.
Innovation and creativity regarding the delivery of patient care is encouraged.
In collaboration with leadership, develops key indicators and collects monthly data to monitor, trend and analyze clinical performance.
Advances the principles of High Reliability to achieve quality improvement and safety objectives.
Helps define overall structure for Quality and Patient Safety activities at Mercy Hospital.
Works with leadership and management to define and communicate Quality and Patient Safety goals and to prepare annual Quality Plan.
Assigns and manages the daily activities of the Quality and Patient Safety Department.
Oversees the extraction and submission of CMS, state and regulatory data ensuring accuracy and completeness.
Serves as the chairperson of the Performance Improvement and Outcomes Committee.
Works collaboratively with all Departments to address potential or actual quality and/or risk issues.
Provides education, structure for Quality and Patient Safety activities serving as a hospital-wide resource.
Translates organizational mission and goals into written quality patient safety and care management operating goals and objectives.
Participates in developing and maintaining processes to ensure that Mercy’s values are visibly reflected in organizational quality patient safety and care management activities.
Supports Mercy’s mission by working to ensure the level of regulatory compliance essential to achievement of organizational goals.
Provides administrative oversight for Quality Professional Practice
Provides leadership for developing and strengthening the professional role of the disciplines.
Ensures that clinical practice models are promoted.
Promotes outcome focused and customer centered care.
Articulates expectations of clinical performance.
Provides guidance to directors/managers regarding practice issues and resource utilization.
Participates and encourages others to participate in professional research presentations and review of published findings.
Provides leadership for evidence-based practice changes
Serves as a resource to other departments on practice issues and trends.
Manages Peer Review
Manages evaluation of quality of care and quality indicators and stewards’ issues though the chain of command according to policy and peer review requirements. Coordinates a system that identifies potential risk management issues as identified in the medical record of command according to policy and peer review requirements.
Coordinates a system that identifies potential risk management issues as identified in the medical record.
Works collaboratively with the medical staff chiefs and others to provide information, monitor performance and assist in physician performance improvement activities
Maintains knowledge of regulations regarding medical staff quality
Presents reports on quality outcomes to medical staff
Provide education, as needed, to the medical staff about regulatory and accreditation requirements
Maintain a collaborative environment that encourages growth through ownership of the areas of responsibility.
Models behavior that invites colleague interaction and demonstrates mutuality.
Communicates in a manner which is open, clear, respectful, and consistent.
Provides strong leadership within and between multidisciplinary departments to promote the goals of the hospital, outpatients and medical practices including employee and physician engagement and retention.
Invites feedback and acknowledges contribution of others. Provides constructive feedback to employees and peers to further NL Mercy goals.
Establishes a leadership development strategy that identifies and promotes a high performing leadership team.
Models collaborative behaviors which facilitate achievement of KPI’s and goals.
Strategically establishes linkages with other key departments which facilitate the goals of patient care delivery.
Handles conflicting situations in a dignified and respectful manner.
Conducts purposeful counseling/coaching sessions with direct reports for purposes of professional development (i.e., percent of performance appraisals done in a timely fashion, one-to-one standing meetings).
Advocates for and assures colleagues attendance to and participation in professional development activities.
Participates actively in leadership forums such as nursing leadership, team building exercises, organization wide efforts such as department/section manager activities, etc.
Supports organizational efforts of establishing and maintaining relationships with communities, benefactors and other employees.
Supports organizational values by recognizing employees in written and verbal modes.
Performs additional duties as required or assigned.
Competencies and Skills
Utilizes Resources Effectively: Understands how to get the most out of available resources and uses cost-benefit thinking in decision-making and in setting priorities. Monitors and analyzes resource usage to identify and eliminate areas of waste and maximize resources. As a leader, defines targets and provides appropriate means; oversees progress and makes adjustments when necessary. Appropriately delegates work, sets clear direction and manages workflow and time.
Behaves with Integrity and Builds Trust: Acts consistently in line with the core values, commitments and rules of conduct. Leads by example and tells the truth. Does what they say they will, when and how they say they will, or communicates an alternate plan.
Cultivates Respect: Treats others fairly, embraces and values differences, and contributes to a culture of diversity, inclusion, empowerment and cooperation.
Demonstrates Emotional Intelligence: Exhibits a high level of self-awareness, self-management, other awareness and relationship management. Conducts themselves in an empathic, appropriate way, with a sense of humor and stimulates a collaborative work environment. Is respectful of the attitudes, feelings, or circumstances of others and aware of the influence of their own behavior on them. Is aware of relevant social, political, system, and professional trends and developments and uses this information for the organization's benefit.
Develops Self and Others:Takes responsibility for engaging in professional self-development activities and programs. Strives to gain insight into their own values, strengths and weaknesses, interests and ambitions and takes action in order to enhance competencies and skills when possible. As a leader, encourages and guides employees towards growth opportunities to enhance performance and help them reach goals. Reviews and analyzes employees' strengths and weaknesses to distinguish their talents and development needs, and to ensure they are enhanced appropriately.
Exercises Sound Judgment & Decision Making: Understands and processes complex information, which allows for appropriate and accountable conclusions. Does not react too quickly or slowly. Balances facts, goals, and potential approaches taking the appropriate criteria into account. Makes active decisions and commits oneself by communicating confidently and respectfully.
Fosters Accountability: Creates and participates in a work environment where people hold themselves and others accountable for processes, results and behaviors. Takes appropriate ownership not only of successes but also mistakes and works to correct them in a timely manner. Demonstrates understanding that we all work as a team and the quality and timeliness of work impacts everyone involved.
Practices Compassion: Exhibits genuine care for people and is available and ready to help; displays a deep awareness of and strong willingness to relieve the suffering of others.
Resolves Conflict: Promptly acts to find alternatives/solutions when team members disagree. Addresses issues in a direct, honest, and appropriate manner. Handles conflicting interests diplomatically and helps to solve them. Transforms difficult situations into teachable moments using respect and accountability .
Required Registered Nurse
Required Master's Degree Undergraduate nursing degree required. Master’s degree in Nursing, Healthcare Administration, or Business is required.
3 year/years of Leadership Experience
5 year/years of Relevant Work Experience
Potential exposure to diseases or infections.
Prolonged periods of sitting.
Prolonged periods of standing.
Prolonged periods of walking.
Work with computers, typing, reading or writing.
Lifting, moving and loading less than 20 pounds.