Chief Quality Officer

Job description

The Chief Quality Officer is a member of the UConn Health Waterbury senior leadership team and has oversight and responsibility over all quality and patient safety-related activities within the hospital and the medical group. The CQO directs the efforts of all performance improvement initiatives to ensure overall compliance with regulatory standards, including national, state, CMS, DPH and other agencies. The Chief Quality Officer will serve in a highly visible leadership role, working collaboratively across the enterprise with clinicians, staff, and administrators to improve overall patient safety and systems-level outcomes. The CQO will provide leadership in developing and implementing a strategy for change management and for strengthening a culture of safety throughout the organization.
Leadership
• Collaboratively set the vision and strategy for clinical excellence and ensure that the operational and clinical systems, resources, and processes are in place to meet clinical quality and patient safety goals.
• Lead the Quality and Safety programs at UCHC Waterbury, including the Quality Assessment and Performance Improvement (QAPI) program.
• Promote, implement, and sustain a Culture of Safety.
• Ensure that UConn Health is a learning organization by applying new methodologies to eliminate waste and empower decision-making at the front lines of the organization.
• Complete Medical Staff quality interventions as needed.
• Drives external reputational management including Leapfrog, CMS Stars, Vizient, public reporting strategy and reputational sensitive quality improvement efforts and communication of same.

Quality Reporting
• Focus on improving healthcare value and quality, including the improvement of clinical outcomes, patient experience, patient safety, costs, revenue, productivity, efficiency, employee and physician satisfaction, and process reliability.
• Develop and utilize organizational dashboards to track Quality & Safety performance.
• Serve as executive sponsor for reporting activities to external quality pay-for-performance data submission and share responsibility with Chief Medical Officer to make final review of data and responses prior to submission.
• Responsible for Quality Assurance and Performance Improvement (QAPI) reports and preparation for monthly QAPI Committee meetings, including maintaining the institutional quality and patient safety scorecard.
• Responsible for updating the annual Clinical Quality and Service Performance Improvement Plan.
• Participate in physician peer review processes and chart reviews, as necessary.
• Maintains physician quality scorecards on all employed and independent physicians on the medical staff working in the hospital.
• Ensure FPPE/OPPE, professional practice evaluations are completed timely and accurately.

Performance Improvement
• Lead or serve as executive sponsor for select Performance Improvement activities within UConn Health.
• Build collaborative partnerships with providers, staff, and leadership to produce measurable improvements in processes and practices that affect patient outcomes and the success of the UConn Health Waterbury initiatives.
• Leads Value Based Care including Pay for performance strategy, quality incentive alignment, risk-based contracting support, population health quality integration.
• Facilitate alignment between improvement initiatives and UConn Health Waterbury’s strategic plan through the execution of the strategies and tactics necessary to successfully improve the outcomes and results of the organization.

Patient Safety
• Proactively address patient safety issues utilizing data, identifying trends, rounding, and determining root causes and solutions.
• Serve as one of UConn Health’s Waterbury Patient Safety Officers.
• Review, investigate and analyze incidents for risk and adverse event identification, loss prevention and claims management purposes, including both potential and actual patient injury. Recommend interventions which will enhance the safety and well-being of patients, staff, and the organization at large.
• Oversee the lifecycle of quality and safety event management, including reporting, classification, and significant event review (root cause analyses, apparent cause analyses, action plan) process. This includes serving as Co-Chair of the Safety Intelligence Review Committee.

Risk Management/Regulatory Readiness
• Serve as Executive Sponsor to Root Cause Analysis (RCA) activities and assist in the development and execution of Corrective Action Plans (CAPs).
• Work collaboratively with the Senior Director of Accreditation and Regulatory Readiness, the Risk Manager and the Office of the General Counsel on policies and procedures as part of the risk reduction strategy. Ensure policies and procedures are current with national standards of practice and in compliance with internal and external regulations.

Quality Data Analytics and Reporting
• Oversee quality data analytics and reporting activities to support Performance Improvement, Patient Safety, Risk Management, and Regulatory Readiness and Accreditation programs and activities.
• Ensures the existence of state-of-the-art scorecards and systems for tracking, evaluating, and communicating patterns in care delivery, patient safety, and health status.
• Responsible for maintaining the facilities system-wide QAPI program; to include data collection, aggregating and analyzing data, and reporting to senior leadership, The Board, and SEC, as needed.
• Serves at clinical information partners regarding E.H.R. optimization, clinical decision support, quality documentation improvement, AI supported quality monitoring, and digital transformation.
• Perform other duties as assigned.

Professional Requirements
• Maintain employee and patient confidentiality and protect sensitive data at all times.
• Maintain regulatory requirements, including all state, federal and local regulations.
• Represent the organization in a positive and professional manner at all times.
• Comply with all organizational policies and standards including those regarding ethical business practices.
• Communicate the mission, ethics, and goals of the organization.
• Participate in performance improvement and continuous quality improvement activities.
• Attend regular staff meetings and in-services.

Qualifications
• Doctor of Medicine (M.D.) or equivalent degree with board certification and recent clinical practice.
• Licensure as a physician in Connecticut required.
• 10 years of progressive leadership experience. A minimum of three (3) years of experience in a hospital facility required. Quality/Patient Safety/Risk leadership experience, preferred.
• Experience leading quality programs; experience within an academic medical center or integrated delivery system with oversight for both inpatient and outpatient settings preferred.
• Track record of scholarship related to quality and safety preferred.
• Proven experience in establishing strategic priorities and building the infrastructure and team to implement large-scale initiatives and behavioral change across the enterprise. Experience utilizing the approaches and methods of process improvement as evidenced by achieving desired outcomes.
• Knowledge of CMS and Joint Commission standards and regulations.
• Experience developing and revising policies and procedures.
• Experience teaching and evaluating clinical performance.
• Demonstrate a level of analytical ability to problem-solve, evaluate, plan, and direct process improvement projects and benchmarking activities for clinical and non-clinical departments.
• Strong organizational and interpersonal skills.
• Ability to convey information effectively in verbal and written communication, and through group/business presentations and meetings.
• Ability to work effectively with groups and in a complex and matrixed organizational structure.