VP- Quality and Clinical Effectiveness

This position develops and drives strategic plans for quality, clinical effectiveness, and safety initiatives in partnership with UC Health’s Chief Clinical Officer and other system leaders. Working closely with the Chief Clinical Officer, the role is accountable for enterprise-wide quality strategy, analytics, prioritization, standards, and assurance. Expected operating model includes the execution of quality and safety improvement within existing clinical and operational leadership structures (COO, CNO, executive committees, service lines, ambulatory operations). The Vice President serves as the enterprise integrator, focusing efforts on the highest‑risk and highest‑impact opportunities, monitoring effectiveness, and escalating barriers when outcomes are not achieved.

The leader must understand clinical practice across an academic environment that includes students, residents, and research, and effectively engage department chairs and faculty in systemwide transformation. Strong analytical expertise is essential, including clinical data analytics, risk adjustment, and translating data into meaningful clinical improvement. Experience with evidence‑based medicine and clinical pathway development is critical. The role must also communicate the economics of quality and clinical effectiveness—particularly their impact on value‑based performance and academic missions—and align physicians, nurses, administrators, and board members around that vision.

Enterprise Quality and Clinical Effectiveness Strategy & System Leadership

• Develop and execute the system-wide quality and clinical effectiveness strategic plan, ensuring alignment with organizational priorities, clinical operations, and financial strategy.
• Drive a culture of high reliability, transparency and Just Culture principles across the enterprise.
• Partner with executive and operational leaders (i.e. COO, CNO, service line leaders, Physician Medical and Administrative Directors) to deliver measurable improvements in quality, safety, and clinical outcomes.
• Establish and sustain strong executive relationships and communication channels to position quality/clinical effectiveness work as an integrated business and clinical imperative.
• Implement and mature HRO principles across the organization, including learning systems, workforce engagement, and safety training.
• Strengthen culture through leadership safety rounding, coaching, and transparent performance feedback loops.
• Coordinate efforts to align strategic priorities, interventions, and standard work to harmonize system-wide approaches and reduce duplication.

Patient Safety Oversight & Harm Reduction

• Lead and continually improve the Enterprise Safety Program, including: 
  • Event reporting and review
  • Root Cause Analysis (RCA) processes
  • Serious Safety Event (SSE) review and mitigation
  • Safety huddles, safety rounds, and leader rounding programs
• Implement and maintain system-wide safety policies and safety culture programs (e.g., TeamSTEPPS, Just Culture).
• Ensure timely identification, tracking, escalation, and mitigation of patient harm events.
• Apply safety improvement initiatives using evidence-based practice, literature, and statistical methods to minimize errors and eliminate preventable harm.

External Quality Programs, Clinical Outcomes Measurement, Analytics & Scorecards 

• Oversee development, interpretation, and dissemination of quality and safety dashboards, scorecards, and metric governance.
• Monitor performance against internal goals and national benchmarks (e.g., Vizient, Leapfrog, CMS Stars) and guide leaders in identifying improvement opportunities.
• Ensure data integrity, consistency, and timeliness for internal performance management and external reporting.
• Update and propose dashboard metrics and goals for quality panels to drive continual improvement enterprise-wide.
• Oversee performance and reporting for external programs (i.e. CMS VBP, Readmissions Reduction, HAC Reduction, Bundled Payments, ACO quality measures, etc.)
• Identify improvement opportunities that enhance reimbursement performance, reduce penalties, and strengthen competitive positioning.

Regulatory, Accreditation & Survey Readiness

• Ensure compliance with The Joint Commission, CMS Conditions of Participation, and state regulatory requirements.
• Oversee accreditation surveys, mock surveys, regulatory audits, and readiness activities across hospitals and clinics.
• Develop corrective action plans, ensure sustainability of improvements, and coordinate system-wide follow-through and learning.

Infection Prevention & Control Leadership

• Supervise system infection prevention monitoring and improvement initiatives.
• Oversee policies/programs to reduce HAIs (e.g., CLABSI, CAUTI, C. diff, SSI) and promote enterprise adoption of best practices.
• Ensure compliance with public health reporting requirements and national infection prevention guidelines (CDC/APIC where applicable).

Executive Governance, Reporting & Stakeholder Communication

• Serve as the primary enterprise quality and safety executive liaison to governance bodies such as: 
  • Quality Committee of the Board
  • System Executive Leadership Team
• Prepare and deliver executive and board-level reports on performance, risks, trends, and strategic initiatives.
• Communicate regularly with executive sponsors, team leaders, and process owners on progress, barriers, critical success factors, and outcomes.
• Collaborate closely with corporate risk, compliance, and legal partners to identify trends, mitigate liability, and strengthen safety systems.
• Lead or participate in sentinel event responses, communication strategies, and enterprise learning.
• Ensure coordinated cross-functional response to high-risk issues and sustainability of mitigation plans.

People Leadership, Team Development & Department Operations

• Lead system quality, safety, infection prevention, accreditation, and related teams; recruit and develop high-performing leaders.
• Direct department operations including human resources functions, budgeting, staffing, and resource allocation.
• Prioritize resources across projects/workload while managing stakeholder expectations and ensuring timely delivery.
• Establish training and professional development programs in QI and safety science for clinicians and staff.
• Model accountability culture principles that are fair, transparent, and learning-oriented.
• Directs, develops, and builds teams with a balanced set of quality and safety improvement.
• Prioritizes resources against projects and workload while effectively managing stakeholder expectations.
• Directly manage department operations, including all human resource and budget- related functions. 
• Model accountability culture principles that are fair, transparent and learning oriented. 

Minimum Required: Bachelor Degree. Preferred: Master Degree. | Minimum Required: 7 - 10 Years equivalent experience with Healthcare quality and safety oversight and leadership. Previous experience as an RN, Pharmacist, MD or other clinical experience is preferred.

REQUIRED SKILLS AND KNOWLEDGE: 

• 6 - 10 Years equivalent experience with Healthcare quality and safety oversight and leadership. Previous experience as an RN, Pharmacist, MD or other clinical experience is preferred.
• Comprehensive understanding of quality assessment, Infection control and patient safety
• Quality and safety experience in academic healthcare setting (system level or multi hospital level oversight) is highly preferred.
• Facility with quality improvement tools and techniques (PDSA, Lean Thinking, Six Sigma, robust process improvement, etc.).
• Experience in achieving results and a documented track record of implementing and accomplishing quality/safety improvements at a health system or multi-hospital level.
• Experience integrating quality across hospital and ambulatory environments. 
• Change Management: Balance of an analytical mindset and a high EQ (emotional quotient) to lead people and drive the change that is required to create this data-driven culture.

WORK ENVIRONMENT 

While the position will work in a normal office environment, travel to the various hospitals and work locations will be necessary. Work hours will vary from time to time depending upon the needs of the business. Regular and predictable on-site attendance is required for this position.