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Nantucket Cottage Hospital VP – Quality, Risk & Patient Experience in Nantucket, Massachusetts

Full-time, Day Shift


Working together with our community to achieve whole person wellness through health and related services.


An island community that enjoys physical, mental, emotional, & spiritual wellness.

Job Summary:

Administrative authority and responsibility for Quality service programs, policies and procedures. Maintains sound organizational relationships, collaboration and shared decision making with the Board of Trustees, Patient Care Assessment Committee (PCAC), Senior Leadership Team, Medical Staff Leadership, physicians, department managers, and all stakeholders. Develops, collaborates, implements, and evaluates long and short-term goals for Quality Management, Risk Management, Care Management, Social Services and Interpreter Services, Medical Staff Services, and Patient Experience Program. Responsible for directing, planning and facilitating process improvements in a safe, consistent environment that promotes quality care and optimal patient outcomes within the constraints of available resources. Performs the duties of the Risk Manager.

_Essential Job Duties and Responsibilities_

  • Initiates and oversees the development of a comprehensive quality, safety and performance improvement plan/program, including the analysis and trending of data related to these initiatives.
  • Coordinates internal performance improvement activities, leading efforts for identifying opportunities for improvement throughout the organization.
  • Coordinates efforts to optimize patient care related to CMS Quality Initiative, Value Based Purchasing and Meaningful Use programs.
  • Provides strategic oversight for patient safety and quality committees with accountability for distribution of organization communication (including pertinent data and analytics).
  • Provides strategic oversight for patient experience program.
  • Provides overall direction necessary to ensure that clinical services are provided in accordance with standards established through state and federal regulations, Centers for Medicare and Medicaid Conditions for Participation, and Joint Commission accreditation standards, including the National Patient Safety Goals. Identifies areas of vulnerability and directs the development of strategies to enhance compliance.
  • Oversees the efforts of Social Services, Case Management, Interpreter Services and Medical Staff Quality.
  • Performs the leadership role in Risk Management.
  • Develops, implements and monitors the Risk Management program.
  • Develops a systematic method for Risk Identification and Analysis for reporting patient related and visitor adverse events.
  • Provides strategic oversight of proactive and reactive patient safety activities including root cause analysis, failure mode effects analysis and Sentinel Event Alerts, and facilities the planning, implementation and evaluation of process changes.
  • Prepares reports and presentations pertaining to: Patient Safety, Performance Improvement, and Regulatory Affairs and others, as requested.
  • Manages appropriate credentialing and privileging of medical staff and assists the President of the Medical Staff as needed.
  • In conjunction with the Medical Staff and system leadership, directs and coordinates safety/quality/performance improvement initiatives.
  • Supports the Medical Staff Quality Committee and the Medical Staff process improvement activities, identifying trends, analyzing data, generating reports and recommending actions to achieve and sustain improvement.
  • Oversees the incident reporting system and ensures compliance with all risk management activities including malpractice claims.
  • Provides support to the President of the Medical Staff for the Medical Staff and Medical Staff Executives Committees.
  • Chairs the NCH Quality Committee.
  • Provides support to the Board-level Chairperson of the Patient Care Assessment Committee.
  • Facilitates the completion of all RCA’s as risks are identified and ensures appropriate follow-up.
  • Abides by the Health Insurance Portability and Accountability privacy and security regulations regarding all aspects of Protected Health Information (PHI).
  • Manges the department budget effectively and determines fiscal requirements and prepares budgetary recommendations.
  • Performs staff performance evaluations establishing a development plan for each employee.
  • Works collaboratively with MGB Quality & Patient Experience teams.
  • Development and revision of annual QI benchmark results.
  • Assessment of quarterly QI results.
  • Production of annual hospital wide QI benchmark results.
  • Performs other duties as assigned.

_Essential Knowledge, Skills, and Experience Required for the Position_

_Knowledge, Skills, and Experience Required_

  • Demonstrated knowledge and application of CQI principals, tools and techniques; statistics; group facilitation skills; medical staff peer review concepts.
  • Knowledge of requirements for maintaining TJC accreditation and standards compliance.
  • Other areas of knowledge include medical records systems; management information systems; applicable statutes and regulatory agency requirements; problem assessment and problem-solving techniques; health care law; health care services.
  • Excellent and effective communication skills, both verbal and written, organization, team building and planning skills.
  • Competence in statistical analysis; ability to interact with individuals and groups at any level; good decision-making skills; personnel management skills.
  • Excellent organizational skills, ability to work on multiple projects under multiple deadlines; highly energetic, and able to embrace challenges and change.
  • Must be a team player and work well with a variety of people in all levels of the organization.
  • Proficient in Microsoft Office applications.
  • Uphold Behavioral Standards in day-to-day interactions.
  • A bachelor’s degree in Nursing, Public Health, Business Administration, Public Administration, or Health Services Administration required.
  • A master’s degree in nursing, Public Health, Business Administration, Public Administration, or Health Services Administration preferred.
  • Minimum of 5 years relevant experience in Quality Improvement, Risk Management, and Accreditation preparation and survey readiness.
  • Minimum of 5 years demonstrated success in leading process improvement and initiatives.
  • Minimum of 2 years of direct experience in Case Management Program management.
  • Experience with the infection prevention requirements for hospital settings.
  • Certification preferred (e.g. Certified Professional in Healthcare Quality (CPHQ)).

_Required Behavioral Skills_

  • Dedication to Excellence:Commitment to work together to meet the needs of those we serve in the most competent, professional and compassionate way.
  • Respect:The dignity and individual rights of every patient and employee are the responsibility of every caregiver, employee and patient.
  • Integrity:Commitment to the highest personal, organizational and ethical standards; providing patient care in a responsible, accountable manner.
  • Quality:Efficient service to the community with the highest level of skill while striving for continuous improvement.
  • Confidentiality:Privileged information is protected, and privacy standards are upheld.
  • Communication:Effective and appropriate exchange of information with our patients, community, staff and partners in healthcare.
  • Safety:Dedicated to providing an emotionally and physically safe and accessible environment for patients, staff and visitors.
  • Teamwork:Fostering an open, creative, and challenging work environment built on respect.

_Special Requirements_

  • Must be available to work in the case of a Hospital declared emergency.
  • Must be available to assist during regulatory agency reviews.

Job: *Professional/Managerial

Organization: *Nantucket Cottage Hospital (NCH)

Title: VP – Quality, Risk & Patient Experience

Location: MA-Nantucket-NCH Nantucket Cottage Hospital

Requisition ID: 3154271