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).

40

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.

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

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

Clinical licensure as applicable

• 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.

Mental, Behavioral and Emotional Abilities:

8 Hours

Does this position formally supervise employees? Yes

• 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.

• 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…