Associate Vice President for Quality, Safety and Regulatory

Exemption Status:

Exempt

Hiring Range:

$142168.00 - $255902.40

(based on a full time schedule of 40 hours per week).

Please note that the final offer will vary based on scheduled hours. Compensation for part-time or reduced schedules will be prorated based on scheduled weekly hours experience skills qualifications and internal equity considerations.

Schedule Details:

Monday through Friday

Scheduled Hours:

40

Shift:

1 - Day Shift 8 Hours (United States of America)

Hours:

40

Cost Center:

10030 - 6212 Office Quality Patient Safety

This position may have a signing bonus available a member of the Recruitment Team will confirm eligibility during the interview process.

Everyone Is a Caregiver

At UMass Memorial Health everyone is a caregiver regardless of their title or responsibilities. Exceptional patient care academic excellence and leading-edge research make UMass Memorial the premier health system of Central Massachusetts and a place where we can help you build the career you deserve. We are more than 20000 employees working together as one health system in a relentless pursuit of healing for our patients community and each other. And everyone in their own unique way plays an important part every day.

Reporting to the Chief Quality Officer the Associate Vice President for Quality Safety and Regulatory (AVP QSR) works collaboratively with the UMMMC/UMMMG Center for Quality and Safety (CQS) leadership team to develop and oversee the implementation of the quality and safety strategy for UMMMC and UMMMG. The AVP QSR will create and maintain a structural framework and manage systems supporting innovative quality safety regulatory and accreditation processes for ongoing sustained improvement ensure compliance with public reporting and licensing regulations set forth by external agencies such as Centers for Medicare and Medicaid Joint Commission and the Massachusetts Department of Public Health; provide leadership and coaching to the Quality Safety and Regulatory Directors and serve as a resource to those who have similar departmental responsibilities within the Medical Center and enhance collaboration of quality and safety work across the system. The AVP QSR works with the Director(s) and members of the CQS team to promote a safety culture that supports UMMMC caregivers as well as improving clinical outcomes and reducing patient and caregiver harm.

I. Major Responsibilities:

1. Design and continuously enhance system readiness for The Joint Commission or other accreditation organizations regarding compliance survey readiness and self-assessments including tracer rounds with defined tools and processes that include feedback from the patient and/ or family rounds with Senior leadership and other unit/service specific tracers. Ensures systems to export tracer and other data is automated and standardized for efficient follow up.

2. Works collaboratively to establish Quality and safety goals that meet or exceed national standards.

3. Evaluate and improve standard work processes and widespread communication for quality and safety improvements that support the organizations Strategic plan. Focus includes but not limited to; SAFER Teams Zero Harm Journey Diversity Equity Inclusion and Belonging and the Culture of Safety.

4. Create internal and external support networks to connect departmental and facility specific quality safety and regulatory functions.

5. Enhances and standardizes the use of automated data in preparing tracking and coordinating communication regarding quality safety and regulatory compliance and improvement.

6. Integrates and standardizes system processes with the Risk Management team for Mandatory Reporting and Serious Event Reporting to meet regulatory requirements and improve patient Safety.

7. Support further integration of a daily management system to support quality and safety problem solving utilizing lean methodology and the electronic daily management system.

8. Directly oversee and provide mentorship to the Directors of Quality Safety and Regulatory to ensure that initiatives are progressing towards goal. Work to develop a culture of learning and continuous performance improvement for the staff in the Quality Safety and Regulatory teams.

Standard Management Level Responsibilities:

and supervises assigned personnel including performance evaluations scheduling orientation and training. Makes recommendations on employee hires transfers promotions salary changes discipline terminations and similar actions. Resolves grievances and other personnel problems within position responsibilities.

and recommends the budgets for the areas managed. Manages activities to ensure financial goals are met.

the assignment of tasks and helps resolve technical and operational problems. Evaluates the impact of solutions to ensure goals are achieved.

effective direction guidance and leadership over the staff for effective teamwork and motivation; and fosters the effective integration of efforts with system-wide initiatives.

and supports diverse views and approaches demonstrates Standards of Respect and contributes to creating and maintaining an environment of professionalism respect tolerance civility and acceptance toward all employees patients and visitors.

diversity into departmental objectives such as hiring promotions training vendor selections etc.

in performance improvement initiatives and demonstrates the use of quality improvement in daily operations.

compliance with regulatory agencies such as Joint Commission DPH (Department of Public Health) etc. Develop and maintains procedures necessary to meet regulatory requirements.

that department complies with established hospital policies quality assurance programs safety and infection control policies and procedures.

adequate equipment and supplies for department.

and maintains established departmental policies procedures and objectives.

compliance to all health and safety regulations and requirements.

regular reliable and predictable attendance.

similar or related duties as required or directed.

All responsibilities are essential job functions.

II. Position Qualifications:

License/Certification/Education:

Required:

1. Masters degree or above in public health nursing health care administration business administration or related areas.

Preferred:

1. RN degree.

2. Lean certification preferred and if not certified must be committed to achieve certification in a reasonable timeframe.

Experience/Skills:

Required:

1. Seven years related experience in management roles.

2. Minimum of 10 years of related professional experience.

3. In depth experience with local state and federal regulatory environment and requirements risk management principles patient safety science publicly reported quality measures operations analysis and quality management improvement methods.

4. Demonstrated leadership change agent with project management skills.

5. Excellent verbal and written communication skills.

6. Ability to effectively utilize a variety of computerized software applications such as spreadsheet word processing relational database and graphics software packages.

Preferred:

with healthcare applications of artificial intelligence.

Unless certification licensure or registration is required an equivalent combination of education and experience which provides proficiency in the areas of responsibility listed in this description may be substituted for the above requirements.

Department-specific competencies and their measurements will be developed and maintained in the individual departments. The competencies will be maintained and attached to the departmental job description. Responsible managers will review competencies with position incumbents.

III. Physical Demands and Environmental Conditions:

Work is considered sedentary. Position requires work indoors in a normal office environment.

All qualified applicants will receive consideration for employment without regard to race color religion sex sexual orientation gender identity national origin disability or protected veteran status.

Were striving to make respect a part of everything we do at UMass Memorial Health for our patients our community and each other. Our six Standards of Respect are: Acknowledge Listen Communicate Be Responsive Be a Team Player and Be Kind. If you share these Standards of Respect we hope you will join our team and help us make respect our standard for everyone every day.

As an equal opportunity and affirmative action employer UMass Memorial Health recognizes the power of a diverse community and encourages applications from individuals with varied experiences perspectives and backgrounds. All qualified applicants will receive consideration for employment without regard to race color religion gender sexual orientation national origin age disability gender identity and expression protected veteran status or other status protected by law.

If you are unable to submit an application because of incompatible assistive technology or a disability please contact us at We will make every effort to respond to your request for disability assistance as soon as possible.

Required Experience:

Exec