Market VP Quality & Infection Prevention - Central Coast

CommonSpirit Health is a nonprofit, Catholic health system dedicated to advancing health for all people. It was created in February 2019 by Catholic Health Initiatives and Dignity Health. With its national office in Chicago and a team of over 150,000 employees and 25,000 physicians and advanced practice clinicians, CommonSpirit operates more than 2,000 care sites from clinics and hospitals to home-based care and virtual care services. Our world needs compassion like never before. Our communities need caring and our families need protection.  CommonSpirit is committed to building healthy communities, advocating for those who are poor and vulnerable, and innovating how and where healing can happen -- both inside our hospitals and out in the community.  CommonSpirit operates 142 hospitals and more than 2,200 care sites across 24 states. In FY 2022, CommonSpirit Health had revenues of $33.9 billion and provided $4.9 billion in charity care, community benefit, and non-reimbursed government programs. Learn more at www.commonspirit.org.

The Market VP Quality & Infection Prevention role provides effective strategic vision, leadership and direction from a quality and patient safety perspective in the overall management of the Central Coast market and California region.  The role  collaborates with other leadership team members in the common goal of standardization, integration and enhancement of the continuum of services available within designated clinical area(s). Oversees the Market’s Performance Improvement, Patient Safety and Infection Prevention Plans, which identify opportunities for improved patient care and outcomes and reductions in harm, with the implementation of evidence- based practices and high reliability organizational processes.

The Regional Director of Infection Prevention is accountable for the design and maintenance of a comprehensive infection prevention program and provides support in all infection prevention related activities. Provides leadership in defining, implementing and integrating acute and ambulatory care quality, safety, service and efficiency strategies into the plans, policies, and organizational processes that affect the market’s Operations and strategic direction. Provides leadership oversight for the market’s quality, patient safety, risk management/mitigation, infection prevention, accreditation/regulatory readiness, organizational compliance, policies and procedures and population health. Reports as directed to the Community Boards.

Essential Key Job Responsibilities:

• Establishes performance improvement goals annually with relevant stakeholders. Ensures the Performance Improvement, Patient Safety, and Infection Prevention Plans and the hospital-focused projects for the year are implemented, and their effectiveness is evaluated annually to meet the market’s and region's goals and advancement. Develops and implements processes and formats that support data collection, aggregation, analysis, and action planning. Assures data is managed appropriately and disseminated to appropriate leadership staff.
• Provides leadership in developing quality improvement, patient safety training, and infection prevention programs; coaches organizational clinical/service lines and operational/support departments in terms of quality improvement principles; Provides direction to the facility quality/infection prevention leadership.
• Oversees the facility process for the events reporting process, root cause analyses, investigations, and requests from the claims team (including management of subpoenas, Summons, and Complaints, and coordination of legal documents related to hospital liability).
• Participates in the national office initiatives and programs to mitigate risks in the region identified at other healthcare facilities, resulting in reduced costs, a decrease in adverse patient events/outcomes, and ultimately safer patient practices and care. Facilitates the advancement of High-Reliability Organizational work and patient safety efforts. Provides direction to the facility's patient safety and risk management leadership.
• Collaborates with the Medical Staff and Market/Organizational Leadership to develop and enhance safe patient care while achieving optimal outcomes, including the market’s peer review program and ongoing and focused practitioner evaluation
• Provides leadership and oversight for accreditation, licensure, and regulatory survey readiness. This includes mock survey tracers to assess survey readiness, education to staff and providers on regulatory compliance, and identification of areas of opportunity and the corresponding actions for compliance at the facility level. Organizes required staff to develop responses to survey deficiencies and oversees response submissions to the appropriate accreditation or regulatory agency.
• Collaborates in advancing population health for the market. Actively promotes a culture of quality and safety throughout ambulatory care facilities. Focused on implementing evidence-based strategies to improve the patient care experience, healthy outcomes, and lower costs for identified patient populations.
• Provide subject matter expertise in established guidelines by AAMI, AORN, CDC, IDSA, and APIC to support acute care and non-acute care compliance with Hospital Accreditation Standards, State and CMS regulations, and other external audits within Infection Prevention standards
• Strategizes performance improvement initiatives that promote consistency in adoption and improved patient outcomes across facilities within the region
• Collaborate with facilities to verify accurate and timely submission of data to internal databases and external agencies
• Represent the region on strategic decisions and initiatives within the Infection Prevention Council and Supply Chain Standardization committees
• Collaborate with national, regional, and facility leaders to implement standardized Infection Prevention strategies within the region

Education:

• Bachelor’s degree required
• Masters trained preferred. Nursing or equivalent clinical degree preferred.

Experience:

• 5 years of administrative quality health care experience and relevant clinical experience required
• 3 years administrative quality leadership required
• Three years’ experience in acute care and five years of Infection Prevention leadership.
• Experience leading quality and safety initiatives across the care continuum and a multi-site network.
• Experience developing and implementing clinical, service and operational process improvement initiatives, both small and large scale

Licensure :

• Certified Professional in Healthcare Quality(CPHQ), or Healthcare Quality and Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment/hire is required.
• Certification in Infection Prevention and Control by the Certification Board of Infection Control and Epidemiology (CBIC) within 2 years of hire.
• CIC -- within 2 years of hire 
• FIRE-SAFETY -- within 90 days of hire