ST. CHARLES HEALTH SYSTEM
TITLE: SVP/Chief Safety and Quality Officer
REPORTS TO POSITION: Chief Physician Executive
DATE LAST REVIEWED: January 28, 2020
OUR VISION: Creating America’s healthiest community,
OUR MISSION: In the spirit of love and compassion, better
health, better care, better value
OUR VALUES: Accountability, Caring and Teamwork
DEPARTMENTAL SUMMARY: Safety and Quality at St. Charles provides
services which promote the physical and psychological safety of
patients, visitors, and caregivers in our multi-hospital health
system. Services include risk assessment, plan development and
implementation, safety and policy / procedure management, and
proactive process improvement to prevent harm and improve
The Chief Safety and Quality Officer (CSQO) provides executive
leadership to ensure that patients receive safe, reliable and
evidence-based care. The position also supports efforts to assure a
safe environment for caregivers to deliver the safest and highest
quality care. This position is responsible for the strategic
deployment of patient safety and quality principles with a focus on
improving patient outcomes, reducing risks, eliminating errors,
implementing best practices and national initiatives, monitoring
compliance, and leading organizational change. The CSQO will
work in a dyad relationship with the system Chief Operating Officer
to align health system clinical performance improvement goals and
create processes and relationships that enable collaboration and
defines accountability for consistent standards wherever patient
care is delivered. This high level position acts as a leader in
change management, is a strong, positive advocate for cultural
change and directs the activity of others. This position will work
closely with hospital and system Chief Medical Officers, Chief
Nursing Officers, Medical Directors, Medical Staff leaders, and St.
Charles Medical Group leaders. The CSQO will also partner with
nursing and other clinical leaders, as well as administrative
support staff that engage in safety and quality oversight and
improvement efforts throughout the system.
This position will be filled by a clinical leader with extensive
patient care experience, either as a physician or a nurse. The
clinician who fills this role will be a member of the Executive
Care Team, the senior executive team of the St. Charles Health
ESSENTIAL FUNCTIONS AND DUTIES:
Leads initiatives to create an exceptional culture of safety
where all caregivers and providers are empowered to identify
quality and safety improvement opportunities as well as the ability
to “stop the line” when clinically appropriate. .
Embraces Lean thinking and fosters relationships with medical
staff to inspire, motivate and lead a culture of Lean within the
Supports system leadership in the execution of strategies
impacting the safety of care delivery programs.
Partners with Chief Nurse Executive, Hospital and Medical Group
Presidents, site leadership and safety and quality teams to ensure
that organizational wide safety and quality initiatives are rolled
out effectively and risk reduction strategies implemented wherever
appropriate while engaging stakeholders in the process.
Manages safety improvements through standardization, risk
mitigation plans, and implementation of best practices impacting
care delivery and provider practices.
Oversees Root Cause Analysis activities evaluating sentinel and
other adverse events. Supports the review, investigation and
analysis of major adverse events and ensures appropriate trainings
and corrective actions are taken to prevent recurrences.
Creates and maintains a strong partnership with hospital and
clinic operational leaders to ensure system-wide goals and
objectives are successfully achieved.
Conducts regular reviews of St. Charles Health System’s safety
and quality performance in partnership with medical staff, quality,
and leadership teams across the organization, providing
expectations, performance planning, feedback, training, development
and performance discussions; defining future state requirements for
operations and ensures the implementation of strategies and
initiatives to effectively meet or exceed business and patient
Actively attends and participates in Executive level meetings,
acute care medical staff and Board quality committees and programs
such as the Multidisciplinary Quality Assurance and Board Patient
Safety and Quality meetings, as well as other committees as
Manages the overall process and improvements for the review,
investigation and closure of appropriate Safety Alert System
Develops and annually reviews the patient safety program with
focused programs and improvements based on internal needs and
external requirements and standards.
Leads and participates in the development and implementation of
system patient safety measurement strategy.
Adheres to the latest thinking in both inpatient and ambulatory
quality, patient safety and patient engagement.
Maintains strong collaboration, communications, and partnership
with the Presidents of the medical staffs and the St. Charles
Monitors, in partnership with the medical staff, the measured
outcomes of hospital clinical care activities, identifies
opportunities for improvement, and leads clinical improvement
activities to improve those measured outcomes; ensures
documentation of the results of hospital wide safety and quality
Monitors literature and professional organizations for new and
revised best practices related to patient safety, serves as a
knowledge leader within the industry.
Oversees the goals and plans for the department and team,
develops tactical strategies to achieve desired vision.
Works closely with the leadership team to establish standards
and measures. Builds relationships with relevant stakeholders to
manage effective processes and programs to improve safety and
Provides strategic ROI analysis for safety initiatives and
manages recommendations, reviews and approves metrics.
Partners with the Chief Operating Officer in overseeing
activities to address and embrace improvements necessary as
outlined by accrediting agencies such as the Joint Commission,
Oregon Health Authority, and others.
Hires, leads, coaches and monitors the performance of all direct
reports, to develop and maintain a high performance team that meets
organizational and department goals.
Conducts all activities with the highest standards of
professionalism and confidentiality. Complies with all applicable
laws, regulations, policies and procedures, supporting the health
system’s corporate integrity efforts by acting in an ethical and
appropriate manner, reporting known or suspected violations of
applicable rules, and cooperating fully with all company
investigations and proceedings.
Delivers customer service and/or patient care in a manner that
promotes goodwill, is timely, efficient and accurate.
Serves as a visible and engaged leader that energizes and
communicates effectively with providers, leadership and staff.
Other duties as assigned.
Supports the vision, mission and values of the organization in
Provides and maintains a safe environment for caregivers,
patients and guests.
Required: MD/DO or RN with Master’s degree required with
graduation from an accredited medical or nursing school. If a
physician, completion of an accredited Residency program
Required: Unrestricted Oregon license as MD / DO or RN.
For physicians, Board Certification in primary specialty.
Valid Oregon driver's license and ability to meet St. Charles
Health System driving requirements.
Preferred: Completion of IHI Patient Safety Officer or
TeamSTEPPS curriculum within 1-year of employment.
Lean Leader Certification
Required: Ten years of experience as a practicing physician or
Preferred: Five years of experience in a leadership position,
overseeing safety and quality initiatives.
PERSONAL PROTECTIVE EQUIPMENT
Must be able to wear appropriate Personal Protective Equipment
(PPE) required to perform the job safely.
ADDITIONAL POSITION INFORMATION:
Expertise in leading management and multi-disciplinary teams in
the achievement of company goals.
Strong knowledge of health care operations/health care delivery,
project management, and quality improvement.
Must have excellent problem identification, analysis and
Strong Knowledge of Patient Safety literature, national best
practices in patient safety and quality, knowledge of accreditation
and regulatory groups' requirements/recommendations, methods and
strategies for successful process improvement, problem solving, and
Ability to motivate, train and manage employees while creating a
positive and collaborative environment.
Demonstrated leadership, team facilitation and presentation
Must possess strong interpersonal, verbal and written
communication skills with ability to interact and communicate
effectively at all levels and across the organization.
Strong interpersonal skills and the highest degree of personal
and professional integrity.
Experience in Lean improvement methodologies.
Continually (75% or more): Sitting, keyboard operation, use of
clear and audible speaking voice and the ability to hear normal
Frequently (50%): Standing, lifting 1-10 pounds,
Occasionally (25%): Bending, reaching overhead, carrying/pushing
or pulling 1-10 pounds.
Rarely (10%): Walking, stooping/kneeling/crouching, climbing
Never (0%): Climbing ladder/step-stool, lifting/carrying/pushing
or pulling 11-50 pounds, operation of a motor vehicle, ability to
hear whispered speech level.
Exposure to Elemental Factors
Never (0%): Heat, cold, wet/slippery area, noise, dust,
vibration, chemical solution, uneven surface.
Blood-Borne Pathogen (BBP) Exposure Category
No Risk for Exposure to BBP
Schedule Weekly Hours:
40 Caregiver Type:
First Shift (United States of America) Is Exempt Position?
Yes Job Family:
VICE PRESIDENT SENIOR Compensation (min.):
0/ Hour Compensation (mid):
0/ Hour Compensation (max):
0/ Hour Scheduled Days of the Week:
Monday-Friday Shift Start & End Time:
Posted 30+ Days Ago
About Us St. Charles Health System is a private, nonprofit
organization, dedicated to providing high-quality care and the
latest in health care technology to the communities it serves.
Headquartered in Bend, Ore., St. Charles is an integrated delivery
system, with a strong focus on population health, that provides a
full range of evidence-based health care services within a
32,000-square-mile area in Central and Eastern Oregon.
The health system owns and operates a trauma level II, tertiary
referral center in Bend, a trauma level III, type B rural hospital
in Redmond, and trauma level IV critical access hospitals in both
Prineville and Madras. As the largest employer in Central Oregon,
St. Charles Health System and St. Charles Medical Group care for
our communities in more than two dozen outpatient clinics and in
more than 20 specialty areas of medicine.
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