Employee Type: Regular Work Shift: Day - 8 hour shift (United States of America) **Join Team Tidelands and help people live better lives through better health!** **Position Summary:** The Associate Vice President (AVP), Quality/Safety oversees quality management and patient safety programs across a complex organization. They ensure diverse strategies and communication for quality and performance improvement, providing an integrated framework for monitoring, evaluating, and improving care. The AVP promotes performance improvement to drive care excellence. Effective leadership is required to reduce risk for the multi-hospital organization, involving board of trustees, senior leadership, hospital leaders, physician partners, employees, patients, and families. The AVP directs safety efforts for all Tidelands Health services, including systematic care practices, institutional patient safety culture, infection prevention, safety/quality related policy and clinical contract management, and education and improvement initiatives. Effective leadership in patient-safety programs, infection prevention, patient-safety data analysis, just culture, change management, and continuous performance improvement methodology is essential to ensure Tidelands Health becomes a High Reliable Organization. Collaboration with various groups and individuals on multiple system initiatives across the enterprise is crucial. **Responsibilities Include:** + CMS Value Based Purchasing surveillance, reporting, and improvement efforts for hospital-acquired conditions and healthcare-associated infections, collaborating with DHEC, CDC, professional organizations, and clinical partners to reduce infections. + Compliance with policies and directs annual performance evaluations for clinical-contractual services. They manage incident command-center operations for infections, pandemics. + Systemwide safety and quality, including intake, review, and assignment to responsible owners. Directs performance improvement projects to enhance patient safety and maintain regulatory excellence. + A patient-safety culture, developing and implementing initiatives promoting transparency, the Just Culture approach, change management, and teamwork. Education and communication of patient-safety improvement topics through the system’s patient safety e-newsletter., monitor literature and professional organizations for new best practices, plan, budget, and manage operational and financial efforts for patient safety, and perform other duties as assigned. + Facility-wide standardization in targeted process improvement initiatives, evaluating success through established criteria and measurement tools, managing project flow and alignment to meet milestones and key performance indicators, and collaborates with stakeholders to drive care excellence across the organization. They lead strategy development for performance improvement through system thinking and safety science application across multiple service lines and care settings. + Directs and leads updates to the Quality Improvement Plan regularly. Develops, implements, and reviews goals, objectives, and priorities to ensure alignment with hospital strategic plans and compliance with federal, state, and local regulations and standards. + Collaborates with facility leadership in establishment of operational performance measurements and targets, as well as the monitoring of trends in key performance indicators to evaluate effectiveness, reliability, and efficiency. + Leads and oversees the quality department with responsibility for care excellence, disease specific care, patient safety, and other aspects of performance improvement across the facility. Effectively manages members of the quality department team. + Develops and monitors the department budget. + Performs regular analysis of facility quality and risk performance data and makes applicable recommendations for process, system, procedure, and operational changes to improve healthcare value and quality. + Maintains oversight of Quality and PI software and reporting systems to meet internal and external reporting requirements and surveys. Assists with selection and installation of software applications. + Monitors completeness, accuracy, and validity of quality files on medical staff and advance practice professionals. + Participates as an active member of peer-review committees; analyzes cases and outcome data and collaborates with physicians to promote and improve practice and optimal patient outcomes. + Collaborates with division and corporate entities and external parties to ensure strategic quality and patient safety initiatives are fully executed at the facility level. Facilitates effective communication with facility and division leadership regarding key clinical performance improvement activities and initiatives. + Serves as a technical advisor, educator and internal consultant to all hospital management, staff, and physicians on the use of performance improvement tools and techniques, analytical techniques, and statistical applications. + Ensures the selection, retention and assignment of qualified competent staff to meet organizational needs. Ensures management of department productivity and work prioritization. + Directs and leads activities of the Quality Committee of the Board in collaboration with facility leadership. + Performs other duties as assigned. + Practices and adheres to the “Code of Conduct” and “Mission and Value Statement.” **Education & Experience:** • Bachelor’s degree in nursing or health-related field, required • Master’s degree in nursing or health-related field, preferred • 3+ years data analysis in a healthcare setting, required • 4+ years experience in healthcare quality with demonstrated leadership, required **Licensure & Certifications:** • Certified Professional in Healthcare Quality (CPHQ) **-OR-** Certification in Healthcare Quality Management (CHCQM), required; must obtain within 12-months of hire date • Currently licensed as a registered nurse or health professional in the state(s) of practice and/or has an active compact license, in accordance with law and regulation, preferred • Healthcare Accreditation Certification Program (HACP), preferred **Physical Requirements** **: Light Physical Agility Test (PAT) Rating** While performing the duties of this job, the employee is frequently (activity or condition exists from 1/3 to 2/3 of the time) required to stand, sit, and walk; frequently to use hands, fingers; and frequently to talk or hear. The employee must exert up to 15 pounds of force occasionally (activity or condition exists up to 1/3 of the time), and/or up to 5 pounds of force frequently, and/or a negligible amount of force constantly to move objects. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Tidelands Health is an equal opportunity employer (EOE). Tidelands Health does not discriminate against employees or applicants for employment on the basis of race, color, creed, religion, age, national origin, disability, marital status, veteran status, gender, genetic information, familial status, or any other legally protected status.