The VP of Quality Improvement and Safety provides leadership and direction to System-wide quality and safety programs, focusing efforts on outcomes which improve the quality of care, patient/resident safety and satisfaction, and efficiency of patient care across the System.  Works collaboratively with members of senior management and physician leaders at the corporate and local levels to design and implement operational strategies and tactics to improve the outcomes desired. Responsible for managing readiness and compliance with regulatory agencies.  Oversees all safety related programs and national patient safety goal implementation and compliance.

Duties and Responsibilities

• Advances the System’s quality program by continuing development of the program’s infrastructure; develops information and tools which can be used for the purposes of analyzing and monitoring quality of care, including indicators of outcomes and cost-effectiveness of patient treatment processes; develops action planning, including training programs, designed to improve performance on system-wide quality indicators.

• Develops quality and safety related goals and objectives to support the system’s operating strategies and mission. Develops and implements initiatives to reach these goals and objectives.

• Responsible for system-wide compliance with all clinical regulatory agencies, including CMS, DNV, state departments of public health and state nursing home regulators.  Represents Covenant Health before such agencies.

• Works with members of management to develop decision-support tools for clinical resource and patient management; works collaboratively with clinical leaders for the development of clinical pathways which support efforts to improve quality and reduce variability.

• Attends, participates and supports the Board Quality and Safety Committee; works closely with and supports the Committee’s Chair; monitors the ongoing Quality initiatives for the system and reports on such at Committee meetings.

• Oversees data-driven performance improvement in the areas of quality, safety, and efficiency of care delivered across the system. 

• Keeps abreast of changes in health care regulations, quality standards, publicly reportable performance indicators, value-based purchasing metrics and pay-for-performance indicators.

• Oversees and works to improve Covenant performance on all publicly reported and value-based purchasing metrics related to quality, safety, and efficiency of care.

• Responsible for metric choices for and maintenance of all quality, safety and efficiency dashboards.  Assures accurate and timely compilation of metric data and insertion into each respective dashboard.

• Supports member organizations in their continuous efforts to improve quality and patient safety within their respective organizations.  Periodic and regular travel to Covenant facilities will be required as needed.

• Fosters effective relationships and strategic partnerships with external bodies involved with quality and safety, including professional organizations, associations, and non-profit agencies.

• Represents Covenant effectively and credibly in a variety of forums and venues relating to patient safety and quality of care. Act as liaison to administration, medical staff, and outside agencies relative to quality/performance improvement activities.

• Works closely and collaboratively with Risk Management Leadership on system-wide adverse event investigating and reporting, including root cause analyses.

• Responsible for developing and updating the annual Covenant Quality Improvement Plan.

• Directly oversees the System Directors of IMG Quality, Post-Acute Quality, and Infection Prevention, as well as the Quality Data and Midas Managers.

• Abides by the Standards of Conduct which is the basis for the Organizational Integrity Program.

• Supports and Promotes the mission and values of Covenant Health Systems and the Catholic Health Ministry.