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AVP, Clinical Quality & Performance Improvement

Ilion, NY - Posted on: Wednesday 07/20/16


Location:  MVHS (FSLH & SEMC)

Type:  Exempt (Salary)

Supervisor:  Sr. Vice President and Chief Quality Officer

Position Summary:

Reporting to the Sr. Vice President / Chief Quality Officer, this position develops, coordinates, and provides leadership for Quality, Performance Improvement, Clinical Transformation, Patient Safety, Accreditation, and provides collaborative support to Infection Prevention, across the Mohawk Valley Health System (MVHS); and realizes the mission and Strategic Quality Plan.  The AVP of Clinical Quality & Performance Improvement directly supervises all members of the quality department and indirectly supervises all directors of quality management throughout the enterprise.  


  • In collaboration with the Senior Leadership, Medical Executive Committee, and Board of Trustees, responsible for the development of the hospital’s quality strategy and annual goals.
  • Responsible for and provides direction to the Quality Department, Outcomes Council, and Patient Safety Committees and provides collaborative support to Infection Prevention.
  • Plans, coordinates and monitors hospital quality incentive programs.
  • Interacts with Executive, Administrative, and Medical Leaders to gain support for Quality initiatives.
  • Coordinates and directs activities related to the DNV accreditation and continuous readiness, and in collaboration with hospital leadership to ensure compliance with all aspects of performance improvement and state and federal requirements.
  • Coordinates responses to ensures that any DNV or DOH deficiency is addressed and resolved.
  • Works to expand knowledge of quality bringing new ideas and concepts by researching and evaluating new and emerging quality initiatives and determine possible incorporation into the health care system.
  • Oversees and directs the development of a comprehensive quality and patient safety program with practice guidelines.
  • Develops an audit structure to meet the needs of the system and are compliant with regulatory agencies.
  • Provides orientation of hospital and ambulatory staff to policies and procedures related to quality and patient safety.
  • Participate with certification processes.
  • Provides communication and education to the Board, Medical Staff, Leadership and Staff regarding the activities of the quality department.
  • Develops and implements unique and varied initiatives aimed at improving systems that result in improved patient care management, improved clinical outcomes, increased work flow efficacy and efficiency.
  • Develops and coordinates continuous improvement programs throughout the organization.
  • Collaborating with other executives and engaging with leaders and clinicians throughout the organization to build quality, efficiency, effectiveness and a sense of shared accountability.
  • Takes a leadership role in evaluating care delivery by developing and strengthening a quality infrastructure that advances the overall quality agenda that is consistent with industry best practices and overall organizational goals.
  • Support operational leaders in the integration of quality and safety to optimize the operating structure and create seamless clinical integration throughout the organization.
  • Strengthening the data and information capabilities of the organization and championing a data-driven environment.
  • Leads the Quality Department within defined financial parameters.


Minimum Education/Licensure:  Master’s degree preferred                       

                                                       Bachelor’s degree required

Qualifications (Work Experience/Education):

  • Master's degree or Masters Candidate preferred in the fields of Nursing, Public Health, Health Policy, Health Administration, or a field related to quality engineering or business improvement; Bachelors Degree required.
  • Clinical background and NYS Licensed Healthcare professional, required.
  • Work requires at least seven years of leadership in a health delivery system, preferably in Quality or Clinical Transformation type role.
  • Work requires broad and comprehensive knowledge of health care delivery, quality management, financial analysis & budgeting, knowledge of medical care process, standards and regulatory agencies’ requirements, healthcare organizational structure, human resources management and medical staff structure.
  • Requires broad and comprehensive knowledge in areas of Quality management, Value Based Purchasing, Infection Prevention, Patient Safety, Accreditation requirements, and other outcome indicators.
  • Work requires a high level of interpersonal skills necessary to interact in complex situations and experience analyzing, managing and communication interpretation of information to all levels leadership and healthcare staff.
  • Proficient to advance knowledge of unit operations, performance improvement, regulatory and professional standards, evidence-based practice patient safely/risk management, and outcomes management.

Physical & Mental Requirements:

  • Must be able to communicate with large groups of people
  • Standing, sitting, bending and walking are standard postures.
  • Lifting requirements of up to 5 pounds frequently and up to 20 pounds occasionally.
  • Must be able to review printed materials