Vice President of Quality and Safety Management

Post# A27833 · Port Charlotte, Florida, USA

Fawcett Memorial Hospital is a 238 bed size facility serving Charlotte County in Port Charlotte, Florida. Fawcett Memorial Hospital and its medical staff represent a broad range of services in many different medical, surgical, diagnostic and rehabilitation specialties. Fawcett is accredited by the Joint Commission and many of our programs have additional recognition by other national certifying agencies. The facility is part of the HCA West Florida Hospital division, which is a comprehensive network of hospitals, outpatient surgery, and diagnostic imaging facilities that meet the healthcare needs of residents and businesses in West Florida communities. Last year the HCA West Florida Division treated approximately 1 million patients. Our parent company, HCA, is the nation’s leading provider of healthcare services operating 163 hospitals and 112 outpatient centers nationwide.

The Vice President of Quality and Safety Management provides leadership and organizational wide direction, development, and implementation of services and programs within assigned areas.

Role Accountabilities include: Responsible for organizational wide direction, development and implementation of services and programs within assigned areas.
Utilizes, integrates, and interprets data to assist organization in its improvement efforts, and promote optimal patient outcomes. Works collaboratively with Senior Management to develop strategic quality initiatives.
Leads organizational performance efforts for JCAHO, core quality measures, COP and regulatory and all other accrediting and regulatory agencies. Ensures compliance with JCAHO, and all legal, regulatory and accrediting agency requirements are met.
Ensures responsibility for organizational wide occurrence reporting system; analyzes and reports trends and identifies appropriate interventions to reduce risk and liability to the organization.
Develops and implements educational programs for employees, medical staff and board members on analysis of risk assessment, historical and concurrent occurrence and claims data and national trends. Facilitates and directs organizational wide risk management program to ensure compliance with statutory mandates, regulatory requirements and accreditation standards of professional organizations, i.e., JCAHO, OSHA, etc.
Participates in and provides leadership for organizational disaster preparedness and patient safety initiatives.
Actively contributes to and works toward hospital wide improvement in meeting core measures, patient safety and service excellence goals
Continuously evaluates work process and design; understands role in ensuring quality/performance improvement, productivity, and service delivery to meet stakeholder needs. Performs duties in accordance with departmental policies and procedures, and recognized professional, quality, patient safety, environmental and infection control standard.
Ensures the coordination of communication from the Quality Committee regarding activities of quality improvement teams and projects throughout the organization. Provides relevant and timely feedback to directors to improve services and processes.
Acts as an expert resource to Senior Leadership, Department Managers, Physicians, and all members of the healthcare team regarding study design, data collection and interpretation, PI quality model, team process and group dynamics. Serves as organizational liaison with Corporate Quality Department.
Demonstrates responsibility and accountability in managing productivity standards. Continuously evaluates and assesses work process/design to enhance productivity and service delivery to meet stakeholder expectations and business goals.
Actively monitors budget and evaluates expenditures on a regular basis. Initiates recommendations to ensure department is operating within budget.
Provides leadership of the Quality Management, Risk Management, Maintains and monitors utilization of resources, physical space, equipment, department protocols, standards, policies, and practices.
Ensures new staff is oriented to specific job duties with particular focus on safety and infection control.
Manages staff performance through regular review, real time feedback, and performance planning. Ensures performance reviews are conducted on time. Actively coaches and mentors staff.
Attends and participates in staff meetings, patient conferences and in-service presentations as appropriate. Completes annual competency training, including but not limited to, infection control, patient safety, quality improvement, MSDS, and OSHA standards (PPE, First Aid and Blood-borne Pathogens, Hazard Communications, Emergency Procedures and Job Safety).


Bachelor's Degree in Nursing; Post Graduate Degree in Nursing or Healthcare related field required or in process
Minimum 5 years of experience in the clinical, risk management, and/or administrative arenas.
Knowledge of State, Federal, and JCAHO regulations. Current Florida licensure as a Registered Nurse. If serving as facility’s primary Risk Manager, VP must have current Florida license in Healthcare Risk Management (FL LHRM). CPHQ (Certified Professional in Healthcare Quality) OR CHCQM (Diplomate in American Board of Quality Assurance and Utilization Review Physicians) Individuals without CPHQ or ABQUARP will be granted a 12 month grace period to obtain CPHQ or ABQAURP to obtain, if all other qualifications are met.

Job Number: 01371-6308


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