AVP Quality, Regulatory and Patient Safety

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates.

The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time).

Scheduled Weekly Hours:

40

Position Overview

SUMMARY (Basic Purpose of the Job)

Provides operational and strategic leadership for the implementation, coordination, and oversight of quality improvement, regulatory compliance, accreditation readiness, and patient safety activities across Capital Health. Translates organizational quality and safety priorities into standardized processes, measurable improvement plans, and sustained operational performance. The role partners closely with executive, physician, nursing, clinical, and administrative leaders to identify performance gaps, implement evidence based improvement strategies, and support the delivery of safe, effective, patient-centered care. Provides leadership to teams responsible for advancing organizational performance and a culture of high reliability and continuous improvement.

MINIMUM REQUIREMENTS

Education:

Master’s degree in healthcare administration, nursing, business administration, or related field required.

Experience:

Seven years or more of progressive hospital or healthcare operational management, including a focus on healthcare quality, patient safety, regulatory compliance, and performance improvement.

Other Credentials:

Clinical licensure as applicable

Knowledge and Skills:

Comprehensive knowledge of healthcare regulations, clinical governance, and accreditation processes. Strong leadership and team-building skills, with demonstrated ability to lead, collaborate, and build consensus across diverse professional teams, fostering a culture of accountability and high performance. Expertise in quality improvement methodologies and data analytics for clinical performance tracking. Excellent communication and presentation skills, with the ability to effectively convey complex information to diverse audiences. Strategic thinker with strong decision-making abilities and a focus on continuous improvement. Financial acumen, with experience managing budgets and aligning clinical performance with financial objectives.

Special Training:

Mental, Behavioral and Emotional Abilities:

Usual Work Day:

8 Hours

Reporting Relationships

Does this position formally supervise employees? Yes

ESSENTIAL FUNCTIONS

Quality

Operationalizes organizational quality priorities and leads implementation of quality improvement initiatives across the health system, ensuring alignment with strategic goals and regulatory requirements.

Oversees systems for tracking, reporting, and analyzing clinical performance metrics. Partners with data analytics and operational leaders to identify performance gaps, establish improvement targets, and monitor sustained results

Ensures timely and accurate external quality reporting, including applicable CMS, Leapfrog, and other required or organizationally selected reporting programs.

Monitors key performance indicators and provides performance reports, trends, risks, and recommended actions to executive leadership and applicable quality committees

Supports Board Quality committee activities and prepares or coordinates quality and safety reporting as assigned.

Regulatory

Interprets regulatory and accreditation requirements and partners with operational leaders to translate requirements in compliant, sustainable practices

Coordinates organizational survey preparedness, tracer activities, corrective action plans, and follow up activities related to accreditation and regulatory findings

Escalates significant regulatory risks, compliance gaps, and barriers to the appropriate executive leader and ensures action plans are developed, monitored, and closed

Patient Safety

Provides leadership for the patient safety program and supports the designated Patient Safety Officer responsibilities as assigned by the organization

Oversees processes for occurrence reporting, event review, trend identification, and escalation of significant safety concerns.

Partners with clinical and operational leaders in the review of series events and supports the development, implementation, and monitoring of corrective and preventative actions.

Advances High Reliability Organization (HRO) principles and safety culture practices in partnership with system leadership.

Promotes a just, learning focused culture that supports transparent reporting, shared accountability, and sustained improvement.

Patient Experience

Oversees patient experience performance metrics and trends, including applicable survey results, complaints, and grievances

Collaborates with the Director of Patient Experience to strengthen communication, responsiveness, service recovery and patient centered care practices across the continuum.

Identifies recurring themes and opportunities from patient feedback and ensures significant concerns, barriers and trends are escalated to appropriate leadership and incorporated into organizational quality and safety priorities.

Leadership & System Collaboration

Provides direct leadership and performance management for assigned quality, regulatory and patient safety leaders and staff

Partners with Vice Presidents, Assistant Vice President, Directors, Managers, physicians, nursing leaders, and other stakeholders to ensure quality safety, and regulatory readiness are integrated into daily operations.

Works closely with operational leaders to establish clear ownership for improvement plans, timelines, measures of success, and sustainment strategies.

Supports development of annual departmental goals, resources needed, and budgets and ensures responsible stewardship of assigned resources.

PHYSICAL DEMANDS AND WORK ENVIRONMENT

Frequent physical demands include:

Occasional physical demands include: Sitting , Standing , Walking , Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Squat/kneel/crawl , Wrist position deviation , Pinching/fine motor activities , Keyboard use/repetitive motion

Continuous physical demands include:

Lifting Floor to Waist 15 lbs. Lifting Waist Level and Above 10 lbs.

Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Minimal Depth Perception, Minimal Hearing

Anticipated Occupational Exposure Risks Include the following: Bloodborne Pathogens , Chemical , Airborne Communicable Disease , Extreme Temperatures , Radiation , Uneven Surfaces or Elevations , Extreme Noise Levels , Dust/Particulate Matter

This position is eligible for the following benefits:

Medical Plan

Prescription drug coverage & In-House Employee Pharmacy

Dental Plan

Vision Plan

Flexible Spending Account (FSA)

- Healthcare FSA

- Dependent Care FSA

Retirement Savings and Investment Plan

Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance

Supplemental Group Term Life & Accidental Death & Dismemberment Insurance

Disability Benefits – Long Term Disability (LTD)

Disability Benefits – Short Term D