Division AVP Quality

This position is incentive eligible.

Job Summary
The Assistant Vice President of Quality (AVPQ) will be responsible for supporting the Division Vice President of Quality in managing and coordinating HCA Mountain Division Quality and Infection Prevention initiatives with a strong focus on Infection Prevention, to support the division's strategic plan, goals, and HCA quality objectives and standards.

In this role, the AVPQ will assist in the facilitation and coordination of activities in: (1) care excellence and infection prevention; (2) process improvement and outcomes management; and (3) regulatory readiness. The role coordinates closely with the HCA Clinical Services Group, the Division Chief Medical Officer, the Division VP of Quality, and the Chief Nursing Executive, ensuring facility compliance with the Joint Commission, CMS Conditions of Participation, licensure, and other standards, rules, and regulations.

Responsibilities

Lead the continuing development of the quality infrastructure across the division.

Ensure resources are leveraged to maximize support of the hospitals and achievement of goals.

Functions as main source of IP contact for division and corporate offices.

Develop goals, objectives, and action plans in accordance with HCA Infection Prevention mission and strategic initiatives to decrease healthcare‑associated infections (HAI) and exposures to infectious agents.

Facilitate the growth of division and hospital knowledge regarding quality and related areas, including dissemination of best practices across the division.

Lead division‑wide standardization in targeted process improvement initiatives, evaluating success through pre‑established criteria.

Lead proactive patient safety activities to create hospitals that are high reliability organizations, reflected in reduced errors, elimination of unsafe processes, and increased involvement of staff and physicians toward a culture of safety.

Contribute to the achievement of business and financial goals through optimal division performance in quality and patient safety.

Interface with appropriate personnel at HCA to leverage corporate resources, programs, tools, and methodologies for the benefit of division hospitals.

Collaborate with and support hospital quality directors to achieve top ranking in national and state publicly reported data initiatives.

Participate in regular analysis of division quality and risk performance data, and plan steps for ongoing improvement.

Work with DVPQ, DCMO, and Division Data Analyst to support data analysis, reporting, and outcomes improvement, contributing to ongoing enhancement of division quality reporting methods and dashboards.

Continuously monitor and evaluate quality outcomes for patient care across the division, noting trends and identifying and prioritizing opportunities to improve.

Ensure the reporting of data to approved third parties, such as Leapfrog, NCDR & STS databases.

Assist facilities in building a proactive quality department by implementing tracer teams responsible for identifying processes that are non‑compliant with Joint Commission and other regulatory requirements.

Facilitate and/or lead clinical process improvement teams as needed to achieve quality improvement goals.

Serve as a regulatory resource regarding state and federal regulations and standards, including but not limited to CMS, Joint Commission, CDC and California and Nevada laws; stay current with NQF, AHRQ, Leapfrog, IHI and other quality performance initiatives.

Demonstrate personal responsibility for professional development, and promote and support such development with division hospital quality directors and risk managers.

Promote a culture that is positive, values individual strengths, takes risks, and is committed to optimal patient care, and compliance with standards.

Attend HCA‑mandated training and meet all ethics and compliance standards and requirements.

Develop and implement division level projects as directed by Division CMO.

Perform all other duties as assigned.

Qualifications

Bachelor’s degree required. Master’s degree preferred (MHA, MBA, or MSN).

5+ years of progressive clinical and quality improvement experience.

3+ years of management experience.

Certified Professional Healthcare Quality (CPHQ) must be obtained within 1 year of employment start date.

Experience in coordinating activities across a range of entities.

Experience with, and knowledge of, hospital regulatory standards and related activities.

Benefits

Comprehensive benefits

for medical, prescription drug, dental, vision, behavioral health and telemedicine services.

Wellbeing support

including free counseling and referral services.

Time away from work

programs for paid time off, paid family leave, long‑ and short‑term disability coverage and leaves of absence.

Savings and retirement resources

including a 401(k) plan with a 100% match on 3% to 9% of pay (based on years of service), Employee Stock Purchase Plan, flexible spending accounts, preferred banking partnerships, retirement readiness tools, rollover support and financial wellbeing counseling.

Education support

through tuition assistance, student loan assistance, certification support, dependent scholarships and a partnership with Galen College of Nursing.

Additional benefits

for fertility and family building, adoption assistance, life insurance, supplemental health protection plans, auto and home insurance, legal counseling, identity theft protection and consumer discounts.

Mountain Healthcare is an equal‑opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.

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