VP Quality

About the role

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The Vice President of Quality provides executive leadership for the hospital's quality, patient safety, regulatory, accreditation, and performance improvement strategy.

This leader serves as a key member of the hospital executive leadership team and partners closely with medical staff, nursing leadership, clinical and operational leaders, and health system quality leadership to advance a culture of high reliability, patient safety, clinical excellence, and continuous improvement.

The Vice President of Quality is a critical member of the hospital's executive leadership team and serves as the bridge between health system quality strategy and local hospital execution.

This leader will be responsible for creating measurable improvements in quality, patient safety, clinical outcomes, regulatory performance, and reliability while strengthening a culture in which every employee and provider understands their role in delivering safe, high-quality care.

The Vice President of Quality is accountable for establishing and executing the hospital's quality and patient safety priorities in alignment with health system strategy, regulatory requirements, accreditation standards, and evidence-based best practices. The position provides leadership for quality measurement, performance improvement, patient safety, regulatory readiness, accreditation, clinical outcomes, and quality reporting.

The Vice President will translate system-level quality strategy into meaningful local execution while ensuring the community hospital maintains strong performance against internal, state, federal, and national quality standards.

Minimum Qualifications

Education, Certification, And/or Licensure

• Bachelor's degree in nursing, healthcare administration, public health, clinical discipline, or related field.

Experience

• 7–10 years of progressive healthcare leadership experience and managing people.
• Significant experience in hospital quality, patient safety, performance improvement, accreditation, regulatory compliance, or clinical operations.
• Demonstrated experience leading multidisciplinary quality improvement initiatives.
• Experience working with physicians, nursing leaders, and hospital executives.
• Strong knowledge of CMS, The Joint Commission, and applicable state regulatory requirements.

Preferred Qualifications

Education, Certification, And/or Licensure

• Master's degree in healthcare administration, nursing, public health, quality, business administration, or related discipline preferred.
• Certification such as CPHQ, CPPS, HACP, FACHE, or comparable professional credential.

Experience

• Experience in a community hospital or multi-hospital health system.
• Experience leading quality functions within an integrated health system.
• Clinical background, particularly nursing or another licensed healthcare profession.
• Experience with high-reliability organizations and patient safety principles.
• Lean, Six Sigma, or other formal performance improvement training.

Core Duties and Responsibilities

• The statements described here are intended to describe the general nature of work being performed by people assigned to this position.
• They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.
• Other duties may be assigned.

• Quality & Patient Safety Leadership
• Provide executive leadership for the hospital's quality and patient safety strategy.
• Establish and maintain a culture of safety, accountability, transparency, and continuous improvement.
• Partner with physicians, nursing, and operational leaders to improve clinical outcomes and patient experience.
• Lead identification, prioritization, and mitigation of clinical quality and patient safety risks.
• Establish hospital quality goals, metrics, dashboards, and performance expectations.
• Monitor trends in quality, safety, outcomes, and patient experience and ensure appropriate action plans are developed and executed.
• Promote evidence-based practices and high-reliability principles throughout the organization.
• Lead initiatives designed to reduce preventable harm, hospital-acquired conditions, readmissions, infections, medication errors, and other adverse outcomes.
• Accreditation & Regulatory Compliance
• Provide executive oversight of hospital readiness for accreditation and regulatory surveys.
• Ensure compliance with requirements of The Joint Commission, CMS, state regulatory agencies, and other applicable accrediting and regulatory bodies.
• Maintain ongoing survey readiness rather than relying solely on preparation for scheduled surveys.
• Partner with clinical and operational leaders to address regulatory deficiencies and sustain corrective actions.
• Oversee development, implementation, and monitoring of corrective action plans resulting from regulatory or accreditation findings.
• Serve as a key executive resource during regulatory and accreditation surveys.
• Performance Improvement
• Lead the hospital's performance improvement framework and methodology.
• Establish priorities for process improvement based on clinical outcomes, patient safety, operational performance, and strategic priorities.
• Facilitate multidisciplinary improvement initiatives using Lean, Six Sigma, PDSA, or other evidence-based improvement methodologies.
• Ensure improvement projects demonstrate measurable and sustainable results.
• Build capability among leaders and frontline employees to identify and solve quality and process problems.
• Promote standardization of clinical and operational processes across the hospital and health system.
• Clinical Quality & Outcomes
• Collaborate with the Chief Medical Officer, Chief Nursing Officer, medical staff leaders, and clinical service line leaders to improve clinical outcomes.
• Monitor performance against nationally recognized quality measures and benchmarks.
• Provide leadership around hospital mortality, complications, readmissions, infections, patient safety events, and other key clinical outcomes.
• Identify opportunities to improve clinical variation, care processes, and utilization.
• Support clinical leaders in developing evidence-based action plans for areas of underperformance.
• Promote use of data and analytics to drive clinical decision-making and improvement.
• Medical Staff Partnership
• Develop strong, collaborative relationships with the medical staff and physician leadership.
• Partner with the Medical Executive Committee and applicable medical staff committees on quality and patient safety matters.
• Support physician engagement in quality improvement and patient safety initiatives.
• Provide quality data and insights to medical staff leadership to facilitate accountability and improvement.
• Assist with physician peer review, professional practice evaluation, and focused professional practice evaluation processes as appropriate.
• Quality Governance
• Establish an effective hospital quality governance structure aligned with the health system's quality framework.
• Chair or provide executive leadership to appropriate quality and patient safety committees.
• Ensure quality committees have meaningful agendas, actionable data, and clear accountability.
• Provide regular reporting to the hospital CEO, Board of Directors, Medical Executive Committee, and health system quality leadership.
• Ensure appropriate escalation of significant quality and patient safety concerns.
• Data, Analytics & Reporting
• Oversee development and use of quality dashboards and performance scorecards.
• Ensure leaders have timely, accurate, and actionable quality information.
• Translate complex quality data into clear recommendations for executives, physicians, managers, and frontline teams.
• Monitor external benchmarks and identify opportunities to improve the hospital's performance relative to peer organizations.
• Ensure accurate and timely submission of required quality data.
• Patient Safety & Event Management
• Establish processes for identification, reporting, investigation, and mitigation of patient safety events.
• Ensure appropriate use of root cause analysis, apparent cause analysis, failure mode and effects analysis, and other safety methodologies.
• Promote a just culture that encourages reporting and learning while maintaining accountability.
• Ensure serious safety events are escalated appropriately and investigated promptly.
• Partner with risk management and legal leadership on significant patient safety events.
• Health System Integration
• Serve as the primary local executive leader for implementation of system quality and patient safety priorities.
• Collaborate with health system quality, patient safety, risk, compliance, infection prevention, clinical informatics, and other system functions.
• Ensure hospital practices are aligned with system standards while appropriately addressing local community needs.
• Participate in system-wide quality councils, committees, and initiatives.
• Identify opportunities to share best practices across hospitals within the health system.
• Leadership & Culture
• Build, develop, and retain a high-performing quality and patient safety team.
• Establish clear expectations, accountability, and professional development opportunities for quality leaders and staff.
• Foster a culture in which quality and safety are viewed as everyone's responsibility.
• Maintain a visible presence with physicians, nurses, leaders, and frontline employees.
• Coach leaders in quality improvement, accountability, and problem-solving.
• Model the organization's values and expected leadership behaviors.
• Leadership Competencies

The successful candidate will demonstrate

• Strategic Leadership – Connects quality strategy to organizational strategy and community needs.
• Clinical Credibility – Builds trust with physicians, nurses, and clinical leaders.
• Influence Without Authority – Drives change across a matrixed health system.
• Patient Safety Mindset – Maintains an unwavering focus on preventing patient harm.
• Data-Driven Decision Making – Uses data to identify problems, prioritize opportunities, and measure results.
• Change Leadership – Successfully leads organizations through complex transformation.
• Accountability – Establishes clear expectations and follows through on results.
• Relationship Building – Creates strong partnerships across clinical and operational functions.
• Communication – Effectively communicates complex quality issues to frontline staff, physicians, executives, and boards.
• Continuous Improvement – Creates an environment where improvement becomes part of daily work.
• Key Performance Measures

Success in this role may be evaluated through

• Hospital quality scorecard performance
• Patient safety event trends
• Serious safety event reduction
• Hospital-acquired condition performance
• Hospital-acquired infection rates
• Mortality and clinical outcomes
• Readmission rates
• Patient experience outcomes
• Regulatory and accreditation performance
• CMS quality measures
• Core measure performance
• Performance improvement project outcomes
• Regulatory survey readiness
• Physician engagement in quality initiatives
• Employee engagement related to safety culture
• Sustainability of improvement initiatives

Physical Requirements

• Ability to maneuver around the hospital setting doing rounds and other employee and patient facing functions.

Working Environment

• Standard office environment

Additional Job Description

Scheduled Weekly Hours: 40

Shift

Exempt/Non-Exempt: United States of America (Exempt)