POSITION SUMMARY

The Assistant Vice President (AVP) of Clinical Excellence and Survey Readiness provides strategic leadership and operational oversight to advance clinical quality, patient safety, and regulatory readiness across the enterprise. This role partners hospital and system leaders to improve clinical outcomes, reduce healthcare-associated infections (HAIs), prevent patient harm, and support performance in CMS quality programs, including CMS 5-Star and other value-based initiatives.

The AVP is responsible for leading and integrating patient safety, quality improvement, survey readiness, accreditation, and regulatory compliance efforts. This leader fosters a culture of high reliability, continuous readiness, accountability, and learning by embedding patient safety science, Just Culture principles, and evidence-based practices into daily operations. The AVP oversees preparedness for regulatory surveys and accreditation activities, ensuring sustained compliance with standards established by The Joint Commission (TJC), the Centers for Medicare & Medicaid Services (CMS), and applicable state and federal regulatory agencies. Through collaboration with Quality, Risk Management, Infection Prevention, and clinical and operational leaders, the AVP drives system-wide strategies that align patient safety, clinical outcomes, and accreditation performance with organizational priorities and community health needs.

Responsibilities

Clinical Outcomes & Quality Support

• Partner with system and hospital leaders to develop, implement, and monitor clinical outcome initiatives focused on patient safety, HAI reduction (CLABSI, CAUTI, SSI, C. difficile, etc.), and harm reduction strategies.
• Support hospitals in achieving and sustaining performance in CMS quality programs, including CMS 5-Star, Value-Based Purchasing, Hospital-Acquired Condition Reduction, and Readmission Reduction Programs.
• Collaborate with Infection Prevention, Pharmacy, and clinical teams to develop systemwide action plans for HAI prevention and compliance with CDC/NHSN reporting requirements.
• Provide oversight and consultation for Patient Safety Programs, including Root Cause Analyses (RCA), Failure Modes and Effects Analysis (FMEA), and implementation of evidence-based practices to prevent adverse events.
• Support hospital leadership in designing and sustaining dashboards, scorecards, and performance metrics for key clinical outcomes.
• Drive system-level initiatives for regulatory compliance that align with best practices in quality, safety, and patient experience.
• Ensure alignment of quality program goals with organizational strategic priorities and community health needs.

Patient Safety

• Provide strategic leadership and operational support for system-wide patient safety programs focused on harm prevention, risk reduction, and high-reliability practices.
• Partner with Quality, Risk Management, and clinical leaders to design, implement, and sustain a comprehensive patient safety program aligned with organizational priorities and regulatory expectations.

• Provide oversight and consultation for adverse event reporting, near-miss reporting, and safety surveillance, ensuring timely review, escalation, and learning.
• Lead or support Root Cause Analyses (RCA), Apparent Cause Analyses (ACA), and Failure Modes and Effects Analysis (FMEA), ensuring corrective actions are effective, measurable, and sustainable.
• Analyze patient safety data, trends, and performance metrics to identify system-level risks, prioritize improvement opportunities, and track progress over time.
• Promote a Just Culture and high-reliability framework that supports transparency, accountability, and frontline engagement.
• Integrate patient safety findings into clinical outcomes improvement initiatives, survey readiness activities, and accreditation performance.
• Support hospitals in preparation for and response to regulatory and accreditation reviews related to patient safety, including CMS Conditions of Participation and The Joint Commission standards.

Survey Readiness & Accreditation

• Lead the development and implementation of the organization's survey readiness strategy, including identifying key standards and regulations related to accreditation for assigned hospitals.
• Oversee the preparation and coordination of internal readiness assessments, mock surveys, and self-assessments to ensure compliance with accrediting and Centers for Medicare & Medicaid Services (CMS), State and/or The Joint Commission (TJC) regulatory bodies.
• Serve as the primary point of contact for all accreditation and survey activities, managing the logistics and coordination of surveys and site visits.
• Serve as primary point of contact for Joint Commission Resources (JCR) Tracers with AMP/Mock Survey Tools and resource.
• Monitor and evaluate the organization's readiness for upcoming surveys, ensuring corrective actions are taken where necessary to maintain compliance.
• Track and report on survey results, Centers for Medicare & Medicaid Services (CMS), State and/or The Joint Commission (TJC) regulatory requirements, and accreditation statuses to senior leadership and relevant stakeholders.
• Work with the Quality Improvement (QI) and Risk Management teams to integrate survey readiness and accreditation standards into daily operations and quality initiatives.
• Lead the development and implementation of action plans to address areas of non-compliance or improvement following internal audits or surveys.
• Facilitate the development and execution of corrective action plans in response to survey findings, ensuring timely resolution and ongoing compliance.
• Support the development and monitoring of key performance indicators (KPIs) related to accreditation standards, compliance, and quality measures.
• Develop and deliver educational programs, workshops, and training to staff and leadership on accreditation standards, regulatory bodies such as, Centers for Medicare & Medicaid Services (CMS) and The Joint Commission (TJC) requirements, and survey processes.
• Act as a liaison between departments and external accreditation and certification regulatory bodies to communicate and resolve survey or accreditation-related issues.

Qualifications

Education & Experience:

• Bachelor's degree in nursing or a related healthcare field required.
• Minimum of five (5) years of progressive experience in healthcare quality, clinical outcomes improvement, patient safety, accreditation, and regulatory compliance.
• Demonstrated experience supporting clinical outcomes performance, including HAI reduction, harm prevention, and CMS quality programs (e.g., CMS 5-Star and Value-Based Purchasing).
• Master's degree in healthcare administration, Nursing, Public Health, or a related field, preferred.
• Certified Professional in Healthcare Quality (CPHQ), preferred.
• Certified Accreditation Professional (CAP), preferred.
• Other relevant certifications in quality, patient safety, compliance, or accreditation, preferred.

Knowledge, Skills & Abilities:

• Strong working knowledge of patient safety science, including event reporting systems, RCA/FMEA methodologies, and safety culture principles.
• Proven expertise in survey readiness and accreditation management, including CMS, state regulatory agencies, and The Joint Commission (TJC).
• Ability to analyze and translate clinical, quality, and patient safety data into actionable insights for executive leadership and frontline teams.
• Strong leadership, communication, and collaboration skills with the ability to influence and partner across clinical, operational, and regulatory stakeholders.