Associate Administrator, Quality Outcomes Management - Quality Assurance - Full Time 8 Hour Days (Exempt) (Non-Union)

The Associate Administrator of Quality (AAQ) position serves as a highly visible champion of quality and patient safety for Keck Medical Center of USC which includes Keck Hospital of USC and Norris Cancer Hospital and licensed clinics, with the goal of achieving world class clinical and patient-centered outcomes that set the standard in healthcare delivery and innovation. The AAQ provides administrative and operational oversight, development and implementation of organization-wide strategies for quality assurance and performance improvement (QAPI), clinical patient safety, accreditation, patient safety, regulatory activities, and support the medical staff peer review functions. This position will partner with medical staff, departments, and leaders across the organization to develop overall strategic direction in the advancement in quality outcomes, reduction of clinical errors, implementation of a system of accountability, developing robust knowledge about errors, maintaining and enhancing accreditations, certifications and publicly reported quality ranking programs. Responsible for ensuring compliance with full accreditation by the Joint Commission (TJC), State Licensing and Certification, and other national and state quality initiatives and verifies that all quality and risk related communication and reporting requirements with regulatory bodies are met. Leads success with facility specific quality measures and other outcome measures and designs and implements systems that result in improved patient care management, improved clinical outcomes, increased workflow efficacy and efficiency, increased cost effectiveness, high patient satisfaction and outstanding performance on key, nationally standardized metrics of quality and safety.

Essential Duties:

• The initial priorities of this position are to: 1. Become fully integrated into and be a trusted and contributing member of Keck’s leadership team by building credibility with leadership through expertise and a collaborative style. 2. Improve the rankings in all publicly reported quality metrics. 3. Conduct an assessment of the Quality Department and make recommendations for improvements. 4. Continue to design structure and automate fluid and rigorous processes, systems and infrastructure that lead to higher efficiency and quality departmental work.
• Excellence in Service and Clinical Quality Primary leadership and direction for creating the infrastructure and resources to support the organization’s quality strategy and programs. Develops and implements service standards to meet patient and other customer definitions of excellence. Ensures continuous compliance with county, state and federal licensing and accrediting body requirements. Identifies and analyzes trends across services in customer satisfaction and patient experience, quality outcomes, and cost using data to guide change in practices. Enhances and accelerates Keck’s goals to raise clinical quality, improve patient experience and provide value to our patients. In collaboration with clinical staff and leadership, participates in the development, monitoring, reporting, and improvement of activities related to clinical pathways and guidelines. Fosters and maintains collaborative relationships with external agencies, purchasers, and stakeholders related to quality/performance initiatives. Reviews and evaluates services of Keck Medical Center of USC that are affected by medical safety/regulatory issues, identified problems, makes recommendations for improvement, and monitors services to ensure that safety/regulatory recommendations are implemented, and the desired results are obtained. Proactively educates Keck Medical Center of USC leadership and medical staff regarding regulatory issues, new statutes/guidelines and medical safety/PI activities. Works directly with all Keck’s quality leads to collaboratively develop clinical and operational quality standards across the system. Integrate and implements approved systems, procedures and policies related to these standards. Develops reports that detail quality improvement activities, including periodic reporting of organizational performance data. Collaborates with other with leaders and clinicians throughout the organization in a hands-on fashion to build quality, efficiency, effectiveness and a sense of shared accountability. Strengthens the data and information capabilities of the organization and championing a data-driven environment. Acts as the Patient Safety Officer and assures implementation of the Hospital(s) Safety Plans. Works closely with Risk Management on any cases or areas identified as opportunities to improve care or outcomes. Assures risk reduction strategies are documented and reported through the system and medical staff structure. Identifies and analyzes trends across services in customer satisfaction and patient experience, quality outcomes and cost using data systematically to develop solutions and guide change in Keck’s practices. Ensures that confidentiality of patient, staff, and appropriate management data is maintained, and delivers immediate and certain consequences when confidentiality is compromised. Identifies and implements unique and varied initiatives aimed at improving patient care quality. Collaborates with other executives and engages with leaders and clinicians throughout the organization and helping develop a culture of continuous improvement and excellence.
• Organizational Strategy and Implementation In conjunction with other medical center executives including the CMO, physician leaders, and staff, the AAQ develops strategy, designs projects and processes to ensure both methodological and operational integrity. Collaborates with executive staff and other directors to understand external market financial, economic, and industry data, identifying market opportunities and threats from a quality standpoint. Provides quality-based direction in the design and implementation of clinically and fiscally responsive program goals and objectives. Ensures continuous improvement and evaluates and makes recommendations regarding ongoing changes required, considering the trends in market demand, research, regulatory standards, and clinical practice. Collaborates with Keck’s leadership to ensure that resources are prioritized and in place (i.e., staff, facilities, equipment, supplies, technology, data, and processes, etc.) and properly utilized to achieve Keck’s objectives through the most effective and efficient operations.
• Human Resource Management Attracts, develops and retains a talented and engaged workforce. Provides vision and leadership to Quality and Outcomes Management and staff in a collaborative environment that offers job satisfaction, performance recognition, and stimulates innovative thinking to accomplish objectives. Ensures that Quality and Outcomes management and staff understand their roles in accomplishing Keck Medical Center of USC’s Team/Division, and organizational strategic objectives. Establishes expectations for high level of performance and holds individuals accountable for achieving them. Ensures the efficacy of systems/ processes to recruit, retain, and develop a high-performance team that meets patient, regulatory, and fiscal requirements. Creates a climate that ensures respect, teamwork, open communication, and professional recognition among a diverse workforce.
• Organizational Leadership Promotes the organization to all constituencies by interpreting and communicating Keck’s mission and values, acting as a loyal, supportive and informed spokesperson. Collaborates with other Keck leaders and professionals to identify, reduce and eliminate barriers within the Center, which may negatively impact cost and quality of services. Identifies areas for self-development and actively seeks opportunities and resources to meet developmental objectives. Models and ensures that managers and staff effectively uphold a customer service orientation to meet expectations of patients and internal and external customers.
• Performs other duties as assigned

Required Qualifications:

• Req Nursing Degree in Nursing or a healthcare related field required.
• Req Master’s degree in a healthcare related field required.

• Req 5 years At least 5 years of progressive leadership experience as an administrator in an acute care environment managing, leading, and developing staff; with recent quality assurance and performance improvement experience including survey experience.
• Req Experience in leading Quality and Compliance Improvement Programs as well as expertise in working with accreditation organizations.
• Req Experience in medical staff peer review processes and support.

• Req Thorough knowledge of the health care industry, its critical issues and major challenges.
• Req Knowledge of healthcare quality principles and regulatory compliance principles.
• Req In-depth knowledge of the principles and practices of quality improvement and patient safety.
• Req In-depth knowledge of audit, control and monitoring processes, and the ability to effectively implement and maintain them.
• Req Knowledge of the principles and practices of medical staff peer review including OPPE and FPPE.
• Req Knowledge of physician service revenue cycle and medical necessity principles.
• Req Knowledge of accreditation organizations such as The Joint Commission, DNV, and specialty certifications such as Commission on Cancer.
• Req Strong knowledge of and ability to identify, implement, monitor and analyze relevant metrics models, and implement effective interventions based on results such as PDSA cycles, DMAIC, Lean Six Sigma, FMEA, and RCA.
• Req Demonstrated knowledge of developing/planning information systems to support quality/disease management infrastructure.
• Req Baseline understanding of health information technology, EHR systems, health information exchange, including data networks, database management and operating systems and interfaces.
• Req Demonstrated experience in program development, training/education, project management.
• Req Knowledge of requirements for external quality and safety organizations, regulatory agencies and accreditation standards.
• Req Demonstrated high level of strategic and analytical ability necessary to formulate short-long range plans and evaluate data required.
• Req Highly developed critical thinking, problem solving, and organizational skills.
• Req Facilitation, problem solving, negotiation and conflict resolution skills.
• Req Ability to foster teamwork across the organizational, mentor staff and other leaders in the areas of Quality/Six Sigma/Process Improvement.
• Req Project management skills including the ability to create, execute and monitor relevant strategic and business plans.
• Req Demonstrated competence at moving concepts from strategy, to tactics, to successful execution.
• Req Strong skills in budget development and management.
• Req Excellent oral and written communication skills.
• Req Strong presentation skills, including the ability to tailor presentations to a specific audience, and address and interact with large groups.
• Req Demonstrated ability to articulate and embrace organizational values, integrate into management practices, and foster their manifestation among staff.
• Req Strong customer service skills.
• Req Exceptional interpersonal skills with ability to establish and maintain effective working relationships with physicians and individuals all levels both internally and externally.
• Req Ability to supervise and develop staff and ensure that direct reports supervise and develop staff in a manner that maximizes employee performance and business results.
• Req Possess the high level of interpersonal skills, tact, and diplomacy required to deal effectively with a wide variety of internal and external stakeholders, and to make effective presentation before groups.
• Req Possess a tolerance for ambiguity and inter-organizational complexity.

Preferred Qualifications:

• Pref Registered Nurse - RN (CA Board of Registered Nursing) Current unrestricted California Registered Nurse (or other clinical) license required with CPHQ certification highly desirable.
• Pref Certification - Job Relevant Additional certification and/or training in healthcare quality or equivalent are a plus. *Examples include Institute for Healthcare Improvement’s (IHI) Breakthrough College Series and Patient Safety Executive Training, NAHQ’s CPHQ certification, Lean certification, or six-sigma certifications.

Required Licenses/Certifications:

• Req Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)
• Req Certified Professional in Healthcare Quality - CPHQ (NAHQ) Required within 6 months of hire.

The annual base salary range for this position is $158,080.00 - $260,832.00. When extending an offer of employment, the University of Southern California considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, key skills, internal peer equity, federal, state, and local laws, contractual stipulations, grant funding, as well as external market and organizational considerations.