• Leads the development of the CHoR Quality and Safety strategic plan in partnership with the CHoR executive leadership team. 

• Coordinates the daily execution of the strategic plan. 

• Supports the oversight and direction of quality improvement and process improvement work of VCUHS led by the Chief Quality and Safety Officer 

• Supports the oversight and direction of quality improvement, safety, and healthcare value projects across CHoR including inpatient units, outpatient clinics, TCU and VTCC. 

• Collaborates with the Medical Director of Performance Improvement & Quality Innovation in alignment with the ACNO and AVP Operations of CHoR. 

• Develops plan to increase CHoR national recognition for Quality Improvement and Safety programs. 

• Designs activities to promote and publicize implementation of safety and quality improvement to employees and medical staff members within CHoR.  

• Assists in planning regular celebration events in partnership with facility executive teams, based on successful efforts in CHoR. 

• Develops, implements, and maintains annual operating budgets for CHoR safety and improvement programs, ensuring that operations are managed within established guidelines. 

• Actively participates in safety initiatives and risk mitigating measures where appropriate and completes all position and unit safety related competencies and requirements on a timely basis. 

• Works with our clinical teams on dissemination of improvement work through conference presentations and peer-reviewed publications 

• Provides, at least quarterly, reports to the CHoR Executive Council and other VCUHS organization leaders regarding program status and impact. 

• Ensures responsibility and visible commitment of diversity, equity and inclusion programs/initiatives through collaboration and implementation of initiatives across the health system.   

Utilize Science of Improvement to Advance Quality, Safety, Service and Performance Improvement Program 

• Effectively uses science of improvement methods and tools including PDSA, Lean, Six Sigma, and other performance improvement and project management tools.  

• Identifies patient safety and performance improvement opportunities within the organization and assists in prioritization of the opportunities establishes processes, conducts analyses and guides associated councils/committees in establishing quality, safety, service performance improvement priorities and meeting performance improvement goals. 

• Designs projects, plans timelines and milestones for complex initiatives; works with key stakeholders to initiate interventions and monitors the impact for sustainability and spread. 

• Leads large complex groups; facilitates teams to achieve stated objectives. 

• Develops, completes, and presents projects and outcomes to a variety of internal and external audiences 

• Cultivates quality improvement and patient safety knowledge within the environment by serving as a subject matter expert in the utilization of science improvement tools/methods to enhance key performance indicators that have been established for safety and service imperatives.  

• Provides education and consultation regarding performance improvement processes, tools, and the use of statistical process control as a method to monitor process/behavior progress for identified improvement projects. 

• Performs and interprets internal and external benchmarking and literature review for assigned groups  

• Assists PI Coordinators and other team members to overcome barriers to their team/project success. 

• Demonstrates excellent communication skills including verbal, nonverbal as well as active listening skills 

Manages Pay-for-Performance/Value Based Reimbursement Program Participation and Contracts 

• Manages Quality Issues including responses to payers and regulators 

• In collaboration with the VCUHS managed care leaders helps assess and evaluate participation in pay-for-performance and value-based reimbursement programs 

• Develops an understanding of the contract/program requirements and guides teams in conducting assessments of VCUHS potential and actual performance. 

• Guides health system leadership in payer contract negotiations relative to quality measures/requirements and Value Based reimbursement to determine opportunities to address. 

• Coordinates information supplied to meet program/contractual obligations and maximize performance incentive payments/minimize penalties. 

• Interacts with owners of areas that may fill contract requirements and provides conduit to supply information to meet contracts; Works directly with stakeholders to overcome barriers and challenges. 

• Facilitates compliance with external regulatory requirements for performance improvement, measurement, and data management. 

• Leads participation in national /state/local benchmarking activities, collaborates on other quality projects, works with PI Coordinators and organizational leaders to maximize outcomes. 

Uses Data, Information Systems & Other Methods to Display Information 

• Coordinates and facilitates the quality and public reporting requirements. 

• Coordinates the preparation, editing and approval all reports as deemed necessary for CHoR at VCU’s quality improvement activities. 

• Manages and coordinates assigned quality dashboard(s), communicates to leadership, staff and assists with the communication to the VCUHS Board of Directors. 

• At least annually, reviews safety, quality, and key performance improvement (KPI) metrics, goals, and works collaboratively with analysts and leadership to revise key performance indicators and dashboards. 

• Works with clinical/data analysts to ensure data integrity. 

Maintains & Updates Knowledge Base 

• Facilitates collaboration and cooperation on safety and improvement initiatives across the VCU Health System with CHoR. 

• Facilitates the identification of best practices and the sharing of tools and techniques between facilities. 

• Stays abreast of new developments in safety and improvement across all industries and provides periodic updates to VCUHS. 

• Completes a minimum of 15 contact hours of continuing education in nursing, performance improvement, data/management/analysis, patient safety, project management, and/or quality engineering as appropriate. This could include CE for related certifications such as CPHQ, PMP, etc. 

Supervisory responsibilities:    

• Supervise CHoR Improvement Science & Analytics Team and program support assistants 

• Supervises daily work of Patient Safety Officer, Quality Program Managers, and PI Coordinators in a matrix reporting system. 

Miscellaneous Responsibilities: 

• Oversees the daily work and progress of the CHoR ISA team. 

• Co-chairs the ISA Steering Committee to ensure strategic alignment with senior leaders 

• Co-Chairs the CHOR Quality Council and ensure its reporting and educational goals 

• Participates in the VCUHS Safety Event Oversight Committee (SEOC) 

• Participates in the CHOR Serious Safety Event Oversight Committee 

• Performs other duties as assigned and/or participates in special projects to support the mission of VCUHS and the assigned areas. 

• Provides assistance to team members. 

• Accepts alternate assignments. 

Required Education: 

• Master’s Degree in healthcare field (e.g. MSHA, MPH, MSN, MHA), Quality Engineering, Business Administration, or related field. 

(Or Combination of education and experience in lieu of a degree.)

Preferred Education: 

• Master’s Degree in either Nursing, health services management or related healthcare field 

• Fellowship in Healthcare Quality or Patient Safety 

• Course work in statistics 

• Supplemental course work in QI, Lean, Six Sigma, quality engineering and/or project management 

Licensure/Certification Required: N/A

Licensure/Certification Preferred: 

• Current license in Commonwealth of Virginia (e.g. Registered Nurse, Pharmacist, Nurse Practitioner or similar) if candidate holds a professional license 

• Certified Professional in Healthcare Quality (CPHQ) 

• Certified Professional in Patient Safety (CPPS) 

• Certified Project Manager 

• Diversity, Equity and Inclusion Certification 

• Basic Life Support (BLS) Certification 

Years and Type of Required Experience Required:  

• (7) years including 3 years of progressively more responsible supervisory or management experience in the healthcare environment 

• (3) years of work experience in quality improvement/quality management, with specific experience that includes: 

• Experience applying the performance improvement methods, tools, and statistical analysis   

• Managing people, teams, and/or projects 

• Previous experience using software applications for data visualization and graphics 

Years and Type of Required Experience Preferred:  

• Experience with organization-wide performance improvement in a large academic medical center with a wide variety of specialty services.  

• Experience managing and directing quality and safety programs. 

• Experience managing quality projects in hospital and ambulatory clinic settings. 

• Experience managing participation in national quality measures, value- based reimbursement or pay for performance initiatives 

• Experience building coalitions and consensus, experience negotiating with physicians and administrators 

• Experience collecting or analyzing data/quality metrics (e.g., core measures, e-clinical quality measures, pay for performance metrics, ambulatory efficiency metrics, etc.) 

• Experience educating clinical and non-clinical staff in improvement methods 

• Experience supporting and/or leading dissemination of improvement work through conference presentations and peer-reviewed publications 

• Experience leading a diverse team 

Other Knowledge, Skills and Abilities Required: 

• Demonstrate aptitude for compliance with VCUHS policies, procedures, and STAR service philosophy. 

• Think independently, organize, plan, and make decisions. 

• Communicate effectively which includes verbal, nonverbal, as well as listening skills. 

• Facilitate groups and teams effectively and promote the VCU Health System’s performance improvement processes, utilizing proven PI tools and methods. 

• Design and complete data analysis methodology accurately. 

• Verbalize knowledge of local, federal, and state laws and regulations as well as TJC standards related to their position’s Chief objective. 

Working Conditions

• Periods of high stress and fluctuating workloads may occur. 

• General office environment. 

• Required to car travel to off-site locations, occasionally in adverse weather conditions.

• Long-distance or air travel as needed- not to exceed 10% travel. 

• Other: May be required to come in during evening or weekend hours to support a clinical team (focus group session, education, or consultation)