Senior Officer of Quality and Safety

The Senior Officer of Quality and Safety holds comprehensive responsibility for overseeing quality assurance, safety protocols, compliance with quality reporting, infection control, and initiatives aimed at performance enhancement. Reporting directly to the President of VCU Health, this individual will collaborate closely with executive leaders throughout the organization to perpetually elevate the quality and safety of care provided to all patients within the Health System.

This role involves working in partnership with senior management and relevant stakeholders to establish and implement strategic objectives concerning quality, safety, and performance enhancement. The Senior Officer acts as the principal advocate and representative for quality and safety initiatives across the entire system. Together with VCU Health's senior leadership, medical staff, and clinical departments, the Senior Officer integrates evidence-based practices into clinical operations.

The Senior Officer is tasked with spearheading educational initiatives for VCU Health team members and executing priorities based on the principles of performance enhancement, safety, and high reliability, promoting the integration of these principles into care delivery processes. This role will also involve close collaboration with senior leadership to develop a cohesive quality and safety program that spans all clinical areas within VCU Health.

Ultimately, this position ensures that all clinical safety and quality protocols, policies, and procedures align with VCU Health's overarching policies and guidelines.

Key Responsibilities: Quality and Safety

Enterprise Responsibilities:

• Design, implement, assess, and refine the mission, vision, and strategic plans for the Safety and Quality Departments and Programs at VCU Health.
• Ensure adherence to mandatory reporting of quality and safety metrics to regulatory bodies.
• Lead initiatives that support VCU Health's enterprise-wide objective of achieving national recognition for delivering safe care to all patients.
• Align and benchmark VCU Health's outcomes and objectives with other national organizations.
• Ensure that training programs on quality and clinical safety are aligned with high reliability principles and are developed, delivered, and managed in accordance with both internal and external standards.
• Establish metrics for internal stakeholders and ensure the reporting of relevant quality and clinical safety metrics to all necessary external entities, including federal and state agencies.
• Champion and lead quality and outcomes management initiatives across VCU Health that incorporate best practices, enhance efficiencies, reduce variability, and lower costs.
• Guide and define methodologies for quality and clinical safety enhancements.
• Promote the implementation of best practices for patient safety and quality.
• Lead evidence-based practices and programs aimed at continuous quality and clinical safety improvement.
• Oversee the distribution of meaningful clinical safety and quality reports to key stakeholders.
• Collaborate closely with Health System leadership and clinicians to ensure a multidisciplinary and organized approach to care practices.
• Foster an environment that encourages learning and accountability.
• Oversee the identification and analysis of serious safety incidents and the implementation of corrective measures.
• Utilize systems thinking, human factors, complexity science, epidemiology principles, and performance improvement strategies to mitigate risks to patients and team members.
• Oversee the development and execution of surveillance programs and databases that monitor hospital-acquired infections (HAIs) and other adverse outcomes.
• Design and implement data-driven, cost-effective interventions to reduce HAIs and occupational exposures.
• Ensure that quality and clinical safety programs and interventions are grounded in sound epidemiological principles and have the potential to enhance clinical outcomes while ideally reducing costs.
• Encourage a culture that supports timely reporting of errors and near-miss events, fostering open discussions about healthcare-associated failures at all organizational levels, and viewing these events as opportunities for learning.
• Maintain a clinical practice in the area of specialty; 80% administrative and 20% clinical, respectively.
• Provide quality education and consultation to patients, families, visitors, and healthcare teams.

Direct Department Responsibilities:

• Exhibit personal ownership and accountability for quality and clinical safety.
• Support Health System reporting of events and near misses, facilitating timely evaluations of clinical safety incidents and implementing planned corrective actions.
• Promote safe practices within VCU Health, ensuring that team members consistently apply safe behaviors in their daily work.
• Create an environment within the Health System where staff feel encouraged and supported to advocate for safety, addressing issues related to technology, policies, systems, and clinical environments as potential contributors to medical errors and adverse events. Proactively identify quality and safety challenges and take effective actions to resolve them.

Talent Strategy and Management Expectations:

• Establish and integrate a collaborative and accountable department aligned with System goals and objectives.
• Develop guidelines and procedures for managing Safety and Quality leaders to ensure the mission and vision of VCU Health are supported and enhanced.
• Supervise and evaluate quality leaders in collaboration with VCU Health business leaders.
• Provide oversight/input into the quality and clinical safety performance of clinical medical directors, in conjunction with the Chief Medical Officer.
• Effectively manage a diverse workforce, demonstrating awareness and appreciation of cultural differences.
• Assist staff in developing skills to address cross-cultural issues.

Visibility and Strategy Expectations:

• Evaluate and advise senior leadership on the potential impact of proposed programs/strategies and regulatory actions on quality and clinical safety at VCU Health.
• Collaborate with VCU Health Leaders to conceive, shape, and drive effective initiatives aimed at improving quality and clinical safety.
• Foster an environment of continuous quality improvement, innovation, and adaptability.
• Translate strategic and tactical business plans into effective clinical safety and quality initiatives.
• Work candidly and collaboratively with the CEO of VCU Health and the senior leadership team.

Miscellaneous Responsibilities:

• Perform other duties as assigned.
• Participate or lead special projects in support of VCU Health and the incumbent's department as needed.
• Assist team members when required.
• Accept alternative assignments when necessary to meet business needs.

Patient Population:

Not applicable to this position.

Employment Qualifications:

Education/Training Required:
Medical degree (MD or DO)

Licensure/Certification Required:
Must be board certified in their specialty or discipline, and within one year of hire, obtain and maintain licensure to practice in the Commonwealth of Virginia.

Licensure/Certification Preferred:

Diversity, Equity, and Inclusion certification preferred.

Minimum Qualifications:

Years and Type of Required Experience:

Required: 10 years of progressive leadership experience in a complex academic medical center or a Council of Teaching Hospital member institution; or demonstrated quality leadership in a non-academic healthcare setting, with a strong professional publication record.

Preferred: 15 years of related leadership experience, including executive-level experience specific to the functional area.

Other Knowledge, Skills, and Abilities Required:

• Experience in establishing mid- and long-term strategic and operational goals for quality and clinical safety that align with organizational objectives.
• Experience in reinforcing a culture of quality, clinical safety, and value across organizations.
• Demonstrated track record of leading and significantly improving quality and clinical safety in a hospital/system using efficient and lean methodologies.
• Experience collaborating with medical staff and all personnel in compliance, performance improvement, or clinical safety areas.
• Demonstrated experience in enhancing physician engagement and developing quality leadership.
• Proven experience in strategic planning, team building, and financial stewardship.
• Strong expertise in quality data metrics and the ability to translate data into actionable items.
• Excellent written and verbal communication skills, computer proficiency, team building, relationship management, and conflict negotiation skills.
• Comprehensive knowledge of clinical effectiveness, evidence-based medicine, high reliability, and quality improvement tools and principles.
• Effective communication and interpersonal skills, with the ability to collaborate and influence stakeholders at various levels.
• Proficiency in utilizing healthcare information systems and data analytics tools.
• A commitment to fostering a culture of continuous improvement, patient safety, and accountability.

Cultural Responsiveness:

• Demonstrate a commitment to diversity, equity, and inclusion through continuous development, modeling inclusive behaviors, and proactively managing bias.

Other Knowledge, Skills, and Abilities Preferred:

• Peer-reviewed publications and/or professional presentations relevant to quality and safety are strongly preferred.

Working Conditions:

• Periods of high stress and fluctuating workloads may occur.
• General office environment.
• Required to travel to off-site locations, occasionally in adverse weather conditions.
• Long-distance or air travel as needed - not to exceed 10% travel.
• May experience periods of constant interruptions.

Physical Requirements:

Physical Demands: Lifting/Carrying (0-50 lbs.), Push/Pull (0-50 lbs.), Stoop, Kneel, Squat, Balance, Bending.

Work Position: Sitting, Walking, Standing.

Additional Physical Requirements/Hazards:

Physical Requirements: Manual dexterity (eye/hand coordination), Hear alarms/telephone/tape recorder, Reach above shoulder, Repetitive arm/hand movements, Finger Dexterity, Color Vision, Acuity - near, Acuity - far.

Hazards: Depth perception.

Mental/Sensory - Emotional:

Mental/Sensory: Strong Recall, Reasoning, Problem Solving, Hearing, Speak Clearly, Write Legibly, Reading, Logical Thinking.

Emotional: Fast-paced environment, Steady Pace, Able to Handle Multiple Priorities, Frequent and Intense Customer Interactions, Noisy Environment, Able to Adapt to Frequent Change.