Job ID: 22-24877 Type: Regular Full-Time System Office 1919 Building
The chief quality officer – vice president of quality and patient safety will build upon Legacy Health’s status as the health care system with the most five-star hospitals in the region. The chief quality officer will develop, recommend, monitor and implement all quality performance initiatives. These initiatives will improve the health of the patients and communities we serve while moving Legacy towards its goal of becoming a health management organization. The chief quality officer sets the organization’s tenor and standard for clinical quality, patient safety and processes. The scope and scale of this responsibility demands a born team leader who knows how to break down difficult concepts into accessible ideas and realistic goals. The ability to communicate across an entire organization with ease and expertise is desired. These collective traits will be complemented by a strong and unflappable determination — but one that also understands that many competing voices are at work inside a major health care system of more than 14,000 people. Our leaders must put the hearts and minds of everyone else before their own. The chief quality officer, like other leaders at Legacy, are devoted to the ideals of diversity, equity and inclusion.
The many qualifications of Legacy’s chief quality officer – vice president of quality and patient safety reflect a complex resume of both hard and emotional skills. A medical degree or international equivalent is required, along with a preference for an additional graduate degree in business or health administration. So is a decade of experience overseeing quality, safety and patient experience. The candidate should be a systems-based thinker and possess knowledge of continuous improvement methodology. The chief quality officer must be able to assess risk, work with the Joint Commission, Centers for Medicare and Medicaid and other regulatory bodies. The cultivation of external partnerships to help improve Legacy’s clinical outcomes would be a necessary adjunct of the position. The chief quality officer collaborates with every level of the organization, including the CEO, the senior executive team, hospital and clinic administrators, board committees and multidisciplinary teams. The candidate will be expected to act consistently with Legacy’s Values in Action and therefore must exemplify the qualities of trust, collegiality and safety among peers, colleagues and subordinates.
Good health for our people, our patients, our communities, and our world — these are not just words. They are commitments that form the core of our mission, and we take them seriously. That mission matches a profound and serious footprint: Legacy Health is a locally owned, nonprofit, six-hospital health system that also includes full-service children’s hospital and more than 70 primary care, specialty and urgent care clinics, a research institute, 14,000 employees and nearly 3,000 health care providers. We provide comprehensive primary, secondary and tertiary care services across the Portland and Vancouver metro area and mid-Willamette Valley. From rural areas to urban centers, we play a critical role in the lives of 2.5 million people.
The CQO Safety acts as a champion to engage all members of our organization in achieving our quality and safety goals in service of our patients and the communities we serve. This role will include some clinical practice.
The CQO is responsible, in conjunction with the SVP & System Chief Medical Officer, for developing, recommending, monitoring, and implementing key quality performance indicators and initiatives that improve the health of our patients and our communities.
Responsibilities for leadership, staff management and direction for establishing and overseeing Legacy’s quality, safety, and patient experience priorities and goals across Legacy’s continuum of care.
Assess external trends in clinical quality and patient safety and recommend organizational direction and targets for Legacy's hospitals and ambulatory clinics.
Works collaboratively with others to prioritize quality initiatives, broadly communicate quality improvement goals, and lead the work of the clinical quality improvement team to ensure that Legacy's hospitals and ambulatory clinics are meeting and exceeding all regulatory, quality and safety requirements.
Works with health care leaders outside of the organization to improve quality and patient safety across the continuum of care.Researches and facilitates quality improvement criteria assessments and projects for benchmarking opportunities, i.e.: Baldridge, HCIA, Premier. Oversees and participates in external quality leadership activities with other health systems and external organizations at the local, state, and national levels to ensure that Legacy is involved in benchmark opportunities and is recognized for its quality achievements.
Plans, leads, and supports activities to ensure compliance with regulatory standards. Responsible for assuring measures are in place to meet TJC accreditation and stay within compliance with all mandated requirements. Applies requirements to identify opportunities for improvement and utilizes requirements when developing solutions to ensure compliance with TJC readiness plan, OSHA, Oregon and Washington state requirements, Federal and CMS requirements, etc.
Champions Legacy’s commitment to a culture of safety by supporting a psychologically safe, high-reliability organization that operates using a just culture framework. Advises the organization on changes necessary to reduce or mitigate risk. Maintains confidentiality. Encourages “near miss” reporting. Utilizes standardized Root Cause Analysis methods to address near miss and adverse outcomes. Evaluates team meeting process to continually improve methods for addressing identified root causes and contributing factors.
Provides leadership for data management process. Directs system-wide quality improvement efforts including the implementation and maintenance of measurement and data systems as well as statistical analyses of quality outcomes and preparation of analytical reports and presentations to determine and initiate action on priorities. Directs the dissemination of performance improvement information within the organization.
Promotes consistent and meaningful quality methodology system-wide.
Provides direction/leadership for standardizing, collating, compiling, and disseminating quality data and data collection processes, such as: system-wide quality dashboard indicators; QP&M benchmarking for best practices; customer service surveying; and system-wide quality report card production. Oversees the development and presentation of organizational performance improvement training to assist with disseminating the use of managing with data throughout the organization.
Provides consultation in Legacy Lean Operating System so that clinical practice improvement and service quality are enhanced. Oversees the development of Quality Plans and ongoing indicators to monitor performance. Uses Legacy problem-solving methods and the Lean Operating System to guide Process Improvement Team progress. Selects, uses, and teaches the Lean tools that correspond to the problem-solving process. Facilitates the development of action plans to address identified opportunities for improvement. Uses knowledge of process improvement (flow charts, process observation, idealized design, etc.) to facilitate simplifying and standardizing processes and equipment whenever possible.
Serves as resource to site-specific quality councils and other committees. Leads the system Quality leadership committee.
Key priorities include creating and executing a 5-year strategic plan for quality, safety, and patient experience that will move us towards top decile performance for all publicly reported measures, as well as our Foundational Metrics.
Leads a cultural transformation as we strive to be the “safest place to deliver and receive care.”
May have clinical patient care responsibilities 5-10% of the time.
The successful candidate will be a talented physician leader with experience as a quality, safety, and patient experience leader.
The ideal candidate will possess:
Minimum of 10 years of progressive experience in quality, safety, and patient experience.
Knowledge in continuous improvement methodology, experience in assessing risk issues, and proven experience working with the Joint Commission, Centers for Medicare and Medicaid and other regulatory bodies.
Experience in cultivating external partnerships to define and measure quality health care and linking it to the improvement of clinical outcomes.
Additional graduate education preferred such as an M.B.A., M.H.S.A., or other pertinent master’s degree.
LEADING AT LEGACY
Demonstrates the ability to act consistently with Legacy’s Values in Action, exemplifies our core organizational values, and exhibits the leadership competencies outlined in Leading at Legacy.
Since 1975, the American Association for Physician Leadership has helped physicians develop their leadership skills through education, career development, thought leadership and community building.
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