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The Vice President, Quality reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.

Overview

The Vice President, Quality is responsible for the overall planning and direction of the NM system-wide quality program. This includes managing internal efforts and external reporting to demonstrate national leadership in quality, equity and safety, while ensuring excellent Patients First performance for NM patients in a culture of safety, continuous improvement and collaboration. The VP facilitates meaningful clinical engagement and works collaboratively with all NM locations, resources and clinical units to measure, evaluate, improve and demonstrate exceptional quality, safety, equity, and value. This person inspires trust and collaboration through compelling influence, humility, respect for others, kindness, expertise, and passion.

The VP for Quality leads the process of identifying the highly credible and relevant national metrics which will inform and drive the performance aims of the health system, both inpatient and ambulatory.  The VP for Quality engages nationally to participate in learning and debate to inform future metrics through such groups as CMS and its technical expert panels, Battelle and the Measures Application Partnership, Vizient steering committees, AAMC, and others.  As aligned with personal experience and interest, the VP for Quality may choose to serve on national advisory or editorial panels related to the future direction of quality measurement and evaluation.  This role is highly visible and is expected to have a national profile.

The VP for Quality identifies needed improvements in care delivery, support processes and the continuum of care, and facilitates development of new models of care delivery to advance performance across NM. This position provides leadership in the alignment of these efforts across the health system through Collaborative Quality committees, delivering high quality wherever our patients live and work.  

This position is responsible to prepare and present routine and special reports for the Board of Directors and its committees, especially the Quality Committee of the Board.

The VP is responsible for design of a health systems approach to Quality within our complex integrated academic health system, attentive to the fulfillment of the potential of a learning health system and benefiting from close working relationships with leading academic experts at our partner, Northwestern University, in equity, implementation science, community engaged health care, health systems outcomes research, and other relevant work. 

The VP implements best practices for high reliability care, efficient and effective management of quality, and aligns to the local and federal legal framework (IMSA, PSO/PSQIA and case law as communicated).  This position has operational system-wide responsibility for Clinical Quality (hospital and ambulatory), Infection Prevention, External Performance Reporting, Accreditation and Clinical Compliance, Clinical Registries, and Medical Ethics.

Reporting Relationships

The VP of Quality reports to the Senior VP for Quality and is supportive and responsive to the hospital and medical group presidents, Chief Medical Officers and Chief Nurse Executives across the system.

Description

• The Vice President, Quality is responsible in collaboration with clinical operations to deliver a culture of high reliability, patient safety and continuous improvement, excellence in performance on national and local key metrics and measures, and dedication to Patients First, in the context of a close partnership with Northwestern University Feinberg School of Medicine and a learning health system.

• In collaboration with the executive leadership, set strategic and operational objectives to improve quality processes and outcomes, equity, safety and value that align with the NM 2035 strategy for exceptional care.  Develop comprehensive strategic and tactical plans to achieve system level goals and revise annual plans accordingly.

• Lead the health system quality oversight committee comprised of all Chief Medical Officers and Chief Nurse Executives to set the system direction for quality and related functions. Consistently drive creative approaches to improve patient care and high reliability, support staff safety and wellness in a fair and just culture, achieve top performance benchmarks as prioritized, engage academic excellence and collaboration, and optimize resource use.

• Serve as Program Lead for the 2023-2029 PCORI Health Systems Implementation Initiative, a competitively awarded program contract to NM to support selected demonstration projects in clinical evidence implementation science and evaluation.  Serve as NM site lead on selected NU research contracts and projects from time to time.  Evaluate and provide letters of support for health services and clinical research at NM, as relevant.   Work to improve the processes and systems to align and integrate NM and NU around research opportunities and priorities.

• Implement and maintain measurement systems (e.g. Vizient and internal tools in electronic data warehouse) to support ongoing quality monitoring and improvement, including clinical quality, equity, safety, infection prevention, accreditation monitoring, and to provide clinical and administrative leadership with the information necessary to monitor clinical effectiveness program performance. Monitor health system strategic objectives on quality to goals; work with leaders as needed to take corrective action to meet goals.

• Work with system clinical operations to measure appropriate indicators so that they meet or exceed all external regulatory, accreditation, and selected national benchmark requirements. Establish indicators for monitoring and evaluating the quality, safety, equity, appropriateness and value of care; assess for continuous improvement in monitored indicators; and direct initiatives for improvement across the continuum of care and across multiple health system entities.   Provide collaboration and support to implement and evaluate new initiatives such as quality equity and patient support for social determinants of health.

• Implement design, support, training and monitoring to assure optimal performance on infection control and prevention for the benefit of patients, visitors and staff.

• Implement systems, communications, training and feedback to assure continuous compliance with relevant regulatory, accreditation and certification requirements.  Lead system thinking on which forms of accreditation and recognition to pursue.

• Provide support and linkages to enable a responsive and skillful Medical Ethics consultation service at the academic medical center, leadership throughout the system, and a blueprint to a more formally structured and resourced Ethics program accessible to all system sites.

• Implement and enhance staff infrastructure and methodologies, including DMAIC, change management, statistical process control, hazard risk analysis, and adaptations of these tools to support equity, to achieve the highest level of performance. Build capacity to identify and implement best practices and to support continued NM excellence in light of future trends in regulatory, reporting and pay-for-performance programs.  Support improvement work to reduce and eliminate harm, payor penalties, and costs of claims

• Support, inspire, coach and train staff to excel locally and extend their knowledge through regional and national posters, presentations, and publications.

• Serve as liaison for clinical quality initiatives with state/federal regulatory agencies, clinicians and executive Leaders and collaborate with other leaders to meet external quality information requests.

• Support chairs, chiefs, medical directors and quality committees across the system, and other key clinical leaders, to utilize evidence-based medicine to reduce unnecessary variation, to standardize care and reduce costs.

• Initiate, oversee and integrate comprehensive safety and QI programs which work to align the health system around excellent care.  Define and coordinate the participation of Infection Prevention / Epidemiology, Accreditation / Clinical Compliance, and related functions such as Patient Safety, Analytics, Clinical Documentation Improvement, Patient Experience, Risk Management, Health Informatics, Compliance and others as necessary.

• Develop system training and education opportunities to advance knowledge, such as quality seminars, patient safety modules, Equity Grand Rounds, Medical Ethics Grand Rounds and Compassion in Action rounds, office hours, seminars for residents and interns.

Establish strong linkages with innovation, patient safety, quality, patient experience, health equity, ethics, health services research, policy, and other constituencies throughout NM and NU.

Required:

• Master’s degree in relevant field
• 7 or more years of experience leading quality and related functions in a large academic medical center or (preferred) health system, with both inpatient and clinic in scope
• Experience at executive level
• Experience in successfully leading quality, performance improvement across the full continuum, including inpatient and ambulatory environments.  Comprehensive subject matter expertise in quality, patient safety, high reliability principles, informatics, evidence-based practices, core measures and DMAIC/Lean processes, as well as public reporting, pay for performance and value-based care.
• Experience working in partnership with multiple constituents throughout an organization. This includes achieving consensus through presentations, thought leadership, partnership, and relationship building throughout the organization.
• Working knowledge of applicable standards and requirements of regulatory, accreditation and licensing agencies. Knowledge of national trends and key issues related to quality, performance improvement, patient safety and population health.
• Experience in achieving results and working with process management. A documented track record of implementing and accomplishing quality / safety improvements in a large complex health care organization or system is required.
• Ability to foster strong collaboration with physician, nursing and other clinical staff, including trainees.

General

• Strong interpersonal, leadership and communication skills necessary to influence every level of the organization.
• Demonstrated ability to develop and execute strategy; demonstrated record of accomplishments and improving outcomes.
• Excellent verbal and written communication skills, presentation skills
• Expert coordination, facilitation, consultation and conflict resolution skills
• Proven team building and leadership capabilities.
• Ability to develop, plan, and implement short and long range goals.
• Skills in analytics, interpretation and use of statistics, relevant measurement methodologies
• Business skills in financial analysis techniques, budget preparation
• Ability to demonstrate a high level of accountability, reliability, and integrity in all interactions and with all constituencies.
• Strong interpersonal skills and the ability to work effectively with a wide range of constituencies in a diverse environment.

Preferred:

• Earned PhD or doctorate in a relevant field.
• Evidence of professional writing and scholarship
• Published professional (collaborative) contributions in science and policy related to quality.
• National leadership, contacts and network in the subject matter
• Relevant association or board membership/service
• Expertise in infection prevention, accreditation, ethics
• Teaching skills

Northwestern Medicine is an affirmative action/equal opportunity employer and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status.