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Job Details

Req Id    59523 
Shift   Days
Shift Hours Worked    7.50 
Employee Status    A1 - Full-Time 
Union  Non-Union

Job Summary

Provide oversight, development and administration of system-wide quality management, performance improvement, and regulatory compliance activities, to achieve the Health System’s over-arching quality and healthcare equity objectives of achieving best performance, regionally, and nationally, in clinical care.

Core Job Responsibilities

• Lead, manage and direct all clinical quality functions across MVHS, including clinical practice effectiveness, quality management and regulatory compliance

• Develop, execute and manage the Health System’s goals for performance improvement and oversee the development, alignment, review and execution of the performance improvement plans for each MVHS facility

-Collaborate with the Health System CPE, CNO, Medical director of Quality, the Board of Trustees, and the Quality Leadership Council to develop the strategic plan for MVHS quality and assist in developing long-range goals, annual objectives, and strategies pertaining to quality, performance improvement and regulatory affairs

• Coordinate provide support for, and serve as staff to the Committees on Quality of the Board of Trustees of the hospitals of the MVHS

• Provide strategic leadership in assessing, developing, and implementing quality data systems and analytic tools

• Anticipate national trends and initiatives in performance improvement, clinical quality, health care informatics, and the use of clinical technology to improve the health care quality

• Develop and implement programs to ensure MVHS and its entities are well positioned for local, state and national clinical regulatory programs, value-based purchasing methodologies, and comparison ratings (e.g. US News, Hospital Compare, Why Not The Best, etc.)

• Collaborate with unit-based clinical leadership and work in partnership with Risk Management to address and improve responses to serious adverse events.

• Provide oversight and administrative direction for assigned departments and administrative functions in all areas of quality, examining and adjusting the deployment of resources across the Health System, as necessary

• Work collaboratively with MVHS CPE and CNO to develop and implement strategies to reduce patient harm

• Foster an environment that supports a Just Culture, in which staff members feel safe to report errors and participate in the analysis and mitigation of them

• Promote the principles of high reliability to drive sustainable performance improvement

• Maintain and disseminate current knowledge of DNV and all other relevant regulatory and reporting organizations’ standards, accreditation and certification processes

• Lead the development and dissemination of system-wide policies and procedures related to regulatory compliance and quality management, ensuring that they are operational across MVHS

• Provide oversight and administrative direction for System-wide Policy Management, including the organization of the Health System Policy Management structure, committee and electronic tracking tool.

• Monitor and promote actions to achieve compliance with all relevant city, state and federal laws, government regulations, accrediting agency standards, and Health System policies


Education Requirements


  • Minimum of seven (7) years of progressively increasing responsibility in health care administration with demonstrated expertise in quality improvement, safety, and regulatory compliance programs experience in planning, liaison and inter-organizational relationships or related administrative or managerial functions
  • Meets Registered Professional Nurse (RN) licensure as outlined by the NYS Education Department.


• Senior clinical health care experience

• Experience at a senior level in quality assurance and performance improvement across and throughout the continuum of care

• Working knowledge and implementation experience with high-reliability process improvement, Malcolm Baldrige National Quality Award methodology, Lean, Six Sigma, etc.

  • Master of Science Degree in Nursing or related field, e.g. Health Care Administration, Education, Business Administration.

Licensure/Certification Requirements

Required: N/A
Preferred: CPHQ certification


EOE AA M/F/Vet/Disability

Qualified applicants will receive consideration for employment without regard to their age, race, religion, national origin, ethnicity, age, gender (including pregnancy, childbirth, et al), sexual orientation, gender identity or expression, protected veteran status, or disability.

Successful candidates might be required to undergo a background verification with an external vendor.

Nearest Major Market: Utica