Education and Work Experience:

• Bachelor's degree in a healthcare-related field, preferably Nursing, or equivalent combination of education/related experience: Required
• Master's Degree: Preferred
• Previous leadership experience in a Quality & Risk Management department setting preferred.
• 7 years' clinical experience in acute care setting, or equivalent combinations of education/related experience: Preferred
• 7 years' healthcare quality leadership, project management/lean or sigma training and experience building or leading a High Reliability Organization (HRO): Preferred
• 5 years' leadership experience: Preferred

Licenses/Certifications:

• Registered Nurse (RN) licensure in the state of Oregon: Required
• Certified Professional in Healthcare Quality (CPHQ): Required
• Basic Life Support (BLS OR HS-BLS OR RQI BLS) certification: Required

Essential Functions:

• Champions clinical quality performance and patient safety, to meet established patient safety, quality and compliance goals. Directs the development of programs and processes related to Quality Management. Provides education to all quality leadership and executives. Facilitates organization wide transition to a High Reliability Organization through development of policies, standards, indicators, implementation and evaluation techniques. Develops policies and procedures, monitors performance, develops and reviews metrics, assesses and prioritizes risk, and reports results to leadership. Serves as a resource to quality teams, medical staff and executives.
• Develops and maintains the quality and patient safety plans for the organization. Develops and maintains a process that engages system and site leaders in the periodic assessment and prioritization of system-wide quality initiatives. Supports organization in developing and building meaningful reports for the quality subcommittee of the board and other leadership committees
• Collaborates with analytics teams to develop and maintain quality metrics that meet required reporting such as Electronic Clinical Quality Measures (eCQM) and more. Works with analytic team and our Electronic Health Record (EHR) vendor to apply meaningful analysis and process improvement. Knowledge leader for Value-Based Purchasing (VBP), Healthcare Associated Infection (HAI), readmissions, mortality and more for any clinical performance programs such as government or commercial pay for performance. Supports quality metrics for contracted services as needed.
• Evaluates various attributes of health care, such as safety, cost, place, treatment, and benefits as compared with standard results, for the purpose of making recommendations for improvement using standardized Performance Improvement (Pl) and Root Cause Analysis (RCA) techniques. Facilitates development of proactive programs to minimize risk. Initiates and monitors efforts to preserve evidence.
• Educates staff regarding information necessary to ensure Quality, Safety, Licensure & Accreditation. Develops and implements an ongoing preparedness for regulatory agencies' plan.
• Performs other job-related duties as assigned.

Organizational Requirements: