System AVP, Acute Care Quality and Patient Safety - NSO 1301 Central St Corporate Office Evanston, USA

NSO 1301 Central St Corporate Office Evanston, USA

9 days ago

System AVP, Acute Care Quality and Patient Safety

Northshore

System Assistant Vice President, Acute Care Quality and Patient Safety

The System Assistant Vice President for Acute Care Quality and Patient Safety provides strategic system level leadership for patient safety, risk management, medical staff peer review, and high reliability across multiple hospitals/institutes. Applies advanced understanding of patient safety and high reliability to recommend changes to processes, procedures, and policies to ensure safety, quality, and clinical excellence are consistently achieved across multiple hospitals/institutes. Additionally, this role holds functional accountability as a business partner for the overall quality program across multiple hospitals and institutes, ensuring that patient safety, quality and clinical excellence are consistently achieved. Reporting to the Vice President of Acute Care Quality, this leader regularly partners with executive leaders and clinical, operational, and business intelligence teams to address problems that are significant and complex. The leader applies advanced understanding of patient safety science to standardize processes, reduce variability, and foster a proactive culture of safety and continuous improvement, empowering staff at all levels to engage in safety initiatives and contribute to a culture of learning. Collaborating closely with executive leaders and clinical teams, this leader ensures alignment with national benchmarks and regulatory standards.

Position Highlights:

Position: System AVP, Acute Care Quality and Patient Safety

Location: Evanston, IL or Warrenville, IL

Full Time/Part Time: Full Time

Hours: Monday-Friday, during normal business hours

Required Travel: frequent travel to other Endeavor Health locations will be required

What you will do:

Quality Business Partner Hospital(s)/Institutes (50%)

Supports business unit to achieve quality/patient safety outcomes, management planning and integration from a system perspective.

Applies advanced understanding of improvement and change management to partner with clinical, operational, and hospital/institute leaders accountable for quality, regulatory compliance, and patient safety.

Sets strategy with executive level leadership to solve for defects in care identified through safety-related incidents, near-misses, sentinel events and other sources of data.

Make decisions and recommendations to address clinical quality problems that are highly varied and significantly complex identifying areas for advance and sustain improvement.

Applies advanced knowledge of improvement science to partner with teams leading to optimal performance in CMS, Leapfrog, Joint Commission, and other agencies.

Ensures adherence to and assists in the achievement of clinical performance outcomes utilizing a collaborative process that focuses on the use of best practices and measurable outcomes.

Cultivates a just culture and staff engagement and well-being by promoting a culture of joy and retention

System Level Functions (50%)

Routinely communicates with executive leaders to provide strategic and operational direction for system-wide patient safety strategy, inclusive of resources, infrastructure, program creation and deployment, benchmarking, data analytics, and communications.

Establishes a system patient safety strategy to identify and address key opportunities to drive the culture of safety.

Creates and leads risk reduction strategies and tactical plans to support a culture of zero-harm that includes accountability measures and follow-up.

Integrates and harmonizes patient safety policies, procedures, and practices across the system.

Leads a system-wide risk management team and activities that align with regulatory standards and operational goals.

Ensures operational compliance with medical staff peer review programs, ensuring high standards and regulatory compliance.

Collaborates with system CMOs to create consistency in OPPE processes.

Apply an equity lens to safety initiatives to ensure fair and safe care across demographics.

What you will need:

Education: Master’s degree in nursing, healthcare administration, public health, or a related field required.

Certification:

Certification as a Certified Professional in Healthcare Quality (CPHQ), Certified Professional in Patient Safety (CPPS) or equivalent certification (preferred).

Lean Six Sigma or similar performance improvement certification (preferred).

High-Reliability Organization (HRO) training or certification (preferred).

Experience:

7 years of progressive leadership experience in healthcare quality, patient safety, or risk management.

3 years of experience as a Director.

Demonstrated success in leading large-scale patient safety initiatives across a multi-hospital health system or integrated healthcare setting.

Experience working with The Joint Commission (TJC), CMS, Leapfrog, and other regulatory bodies to ensure compliance and readiness.

Proven ability to implement high-reliability principles and foster a culture of safety and continuous learning.

Extensive experience in performance improvement methodologies such as PDSA, RCA, FMEA, and ACA.

Unique or Preferred Skills:

In-depth understanding of clinical quality, patient safety, risk management, and regulatory compliance in acute care settings.

Expertise in data analytics and performance monitoring tools (e.g., Vizient, RL Solutions, Culture of Safety Surveys).

Experience partnering with disciplines in developing dashboards, scorecards, and data visualizations to monitor trends and guide decision-making.

Ability to track, trend, and interpret safety metrics and implement corrective actions using data-driven insights.

Proven ability to collaborate with interdisciplinary leaders (CNOs, CMOs, Presidents) and workgroups to align system and hospital-based priorities.

Ability to foster cross-disciplinary teamwork to achieve quality outcomes.

Experience leading peer review and professional practice evaluation processes (OPPE, FPPE) to ensure clinical excellence and accountability.

Ability to engage frontline staff through safety huddles, leadership walk-arounds, and shared learning initiatives.