Chief Quality

The Chief Quality and Safety Officer has system responsibility for quality, safety, quality reporting compliance, infection prevention and performance improvement related activities. Reporting to the President, VCU Medical Center, the individual in this role will work closely with senior leaders across the enterprise to continuously improve the quality and safety of care delivered to all Health System patients.

The Chief Quality and Safety Officer (CQSO) collaborates with senior leaders and other appropriate members in establishing and executing the system’s strategic priorities around quality, safety, and performance improvement. The CQSO oversees and serves as the accountable chief champion and spokesperson for quality, safety, performance improvement system wide. With VCU Health System senior leadership, medical staff, and clinical areas, the CQSO deploys evidence-based medicine into clinical practice

.
The Chief Quality and Safety Officer is responsible for leading efforts to educate VCUHS team members and execute priorities in the principles of performance improvement, safety, and high reliability, and will promote the incorporation of these principles into care delivery processes. The CQSO will work closely with VCUHS senior leadership to create an integrated quality and safety program crossing all clinical domains within VCU Health Syste

m.
Finally, this role ensures all VCU Health System clinical safety and quality protocols, policies and procedures both comply with and are aligned with the VCU Health System’s policies and procedur

es.
Performance Expectation: Quality and Sa

fetyResponsibility to Enterpr

• ise:Design, implement, evaluate, and refine the mission, vision, and strategic plans of VCUHS’ Safety and Quality Departments and Progr
• ams.Ensure compliance with required reporting of quality and safety metrics to governmental and regulatory agenc
• ies.Lead activities to support VCUHS’ enterprise-wide goal of being nationally recognized for providing safe care for all its patie
• nts.Appropriately align and benchmark VCUHS outcomes and goals to other organizations nationa
• lly.Ensure that quality and clinical safety training programs are aligned with high reliability concepts, and are created, delivered, and managed according to internal and external guideli
• nes.Establish measurements for internal stakeholders and assure reporting of relevant quality and clinical safety metrics to all required external entities, including federal and st
• ate.Champion and lead quality and outcomes management initiatives across VCU Health that incorporate best practices, create efficiencies, reduce variation and decrease c
• ost.Guide and define methodologies for quality and clinical safety improvem
• ent.Foster implementation of best practices for patient safety and qual
• ity.Implement and lead evidence-based practice and programs to drive continual quality and clinical safety improvem
• ent.Oversee the dissemination of meaningful clinical safety and quality reports to key stakehold
• ers.Closely collaborate with Health System leadership and clinicians while ensuring a multidisciplinary and organized approach to care practi
• ces.Foster an environment that supports learning and accountabil
• ity.Oversee identification and analysis of serious safety events and implementation of corrective acti
• ons.Utilize systems thinking, human factors, complexity science, principles of epidemiology and performance improvement to prevent and mitigate risks to patients and team memb
• ers.Oversee the development and implementation of surveillance programs and databases that track hospital acquired infections (HAI) and other adverse outco
• mes.Oversee the design and implementation of data-driven, cost-effective interventions to reduce HAIs and occupational exposu
• res.Ensure that quality and clinical safety programs and interventions are based on sound principles of epidemiology and offer meaningful potential to improve clinical outcomes and ideally, decrease co
• sts.Promote a culture that supports timely reporting of errors and near-miss events, open discussion of health care-associated failure events at all organizational levels, and the value of approaching these events as learning opportunit
• ies.Maintain a clinical practice in area of specialty; 80/20 admin/clinical, respectiv
• ely.Support quality education and consultation to patients, families, visitors and healthcare te

ams.
Responsibility to Direct Depart

• ment:Demonstrate personal ownership and accountability for quality and clinical sa
• fety.Support Health System reporting of events and near misses. Facilitate timely evaluation of clinical safety events and implement planned corrective act
• ions.Promote safe behavior within the VCU Health System; take caution to ensure that VCU Health System team members apply safe behaviors to their everyday
• work.Establish a Health System environment in which staff are encouraged and supported to speak up for safety. Look beyond human and team behavior to consider problems with technology, policies, systems, and clinical environments as possible contributors to medical errors and adverse events. Proactively identify quality and safety problems and take effective action to address

them.
Performance Expectat

ions: Talent Strategy and Manag

• ement:Establish and integrate a collaborative and accountable department to System goals and objec
• tives.Develop guidelines and procedures for the management of Safety and Quality leaders to ensure the mission and vision of VCUHS is supported and enh
• anced.Supervise and evaluate quality leaders in collaboration with VCUHS business le
• aders.Provide oversight/input into the quality and clinical safety performance of the clinical medical directors, in conjunction with th
• e CMO.Effectively manage a diverse workforce by demonstrating awareness and appreciation of cultural differ
• ences.Assist staff in developing awareness/appreciation skills to address cross-cultural i

ssues.
Visibility (St

• rategy)Evaluate and advise senior leadership on the potential impact of proposed programs/strategies and regulatory action on quality and clinical safety at
• VCUHS.Partner with VCUHS Leaders, to conceive, shape and drive effective initiatives to improve quality and clinical
• safety.Foster an environment of continuous quality improvement, innovation, and a
• gility.Translate strategic and tactical business plans into effective clinical safety and quality initi
• atives.Work candidly and collaboratively with VCHUS’ CEO and senior leadershi

p team.
Performance Expectation: Miscellaneous Responsi

• bilitiesPerform other duties as a
• ssigned.Able and willing to participate or lead special projects in support of VCUHS and the incumbent’s Dep
• artment.Assist team members when r
• equired.Accept alternate assignments when necessary to fulfill busines

s needs.
Employment Quali

ficationsEducation/training R

equired: 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 o

f Virginia
Licensure/Certification

Preferred:Diversity, Equity, and Inclusion certificatio

n preferred
Minimum Qu

alificationsYears and Type of Required

E

• xperience: Required: 10 years of progressive leadership experience in a complex academic medical center or Council of Teaching Hospital member institution; or demonstrated quality leadership in a non-academic healthcare setting, but with a strong professional publica
• tion record.Preferred: 15 years of related leadership experience to include executive level experience specific to func

tional area.
Other Knowledge, Skills, and Abili

• ties RequiredExperience establishing mid- and long-term strategic and operational goals for quality and clinical safety that align with organiza
• tional goals.Experience strengthening and reinforcing a culture of quality, clinical safety, and value across o
• rganizations.Demonstrated and measurable track record of leading and significantly improving quality and clinical safety in a hospital/system by using efficient and lean
• methodology.Experience in working with medical staff and all staff in areas of compliance, performance improvement, or cli
• nical safety.Demonstrated and measurable experience in improving physician engagement and developing qualit
• y leadership.Demonstrated and measurable experience in strategic planning, team building, and financial
• stewardship.Strong expertise in quality data metrics and the ability to translate data to acti
• onable items.Excellent written and verbal communication skills, computer proficiency, team building, relationship management, and conflict negotiation (problem-sol
• ving) skills.Comprehensive knowledge and understanding of clinical effectiveness, evidence-based medicine, high reliability, and quality improvement tools an
• d principles.Effective communication and interpersonal skills, with the ability to collaborate and influence stakeholders at va
• rious levels.Proficiency in utilizing healthcare information systems and data ana
• lytics tools.A commitment to fostering a cultural of continuous improvement, patient safety, and ac

countability.
Cultural

• ResponsivenessDemonstrate a commitment to diversity, equity, and inclusion through continuous development, modeling inclusive behaviors, and proactively

managing bias.
Other Knowledge, Skills, and Abili

• ties Preferred:Peer reviewed publications and/or professional presentations relevant to quality and safety stro