Job Description

Location: Steward Health Care
Posted Date: 2/9/2022


(Briefly describe the overall purpose of this position - Why does it exist and how does it contribute to the overall organization?)

Reporting to the Associate Chief Medical Officer, this position is a key member of the leadership team assessing and developing quality and patient safety goals, emphasizing High Reliability and Just Culture while also directing and overseeing the training and field work of a cross-sectional variety of clinical and operational Performance Improvement initiatives. This role provides solutions for clinical risk vulnerabilities and informs and supports the direction of Steward’s quality and patient safety division, fostering engagement and success in such measures as Leapfrog, CMS star ratings HCAHPS, and PSI; and ensuring, in conjunction with regulatory and risk leadership, compliance with TJC, DNV, and CMS. In addition, this role must be an active partner and participant in all clinical safety event reviews, including but not limited to Root Causes Analysis and Failure Mode Evaluation Analysis, providing regular and routine insight and evidence-based guidance. This position requires close collaboration across multiple disciplines with both internal and external partners, and must align tightly with executives, physicians, nursing, care transitions and operational ancillary services to promote an environment of superior care and equity across a multi-state, multi-site Network. In addition, this role coordinates activities with the data analytics team to provide business and strategic guidance on necessary data integration, reporting measures, and regulatory requirements.


(Use bullets for specific responsibilities)

  • Assists the Associate Chief Medical Officer in driving cultural change, promoting organizational progression towards becoming a high reliability organization with a robust safety culture
  • Supervises the activities of assigned quality and performance improvement teams with goal of creating a highly collaborative work environment committed to outstanding performance and outcomes.
  • Oversees and directs daily operations and training of Practice Performance Improvement to drive quality, patient safety, and clinical integration.
  • Fosters the professional and personal development of team members and assists in recruitment, retention, and succession planning efforts.
  • Assists the Associate Chief Medical Officer in setting priorities for quality and patient safety and optimally deploying resources to meet them.
  • Serves directly as a quality and safety improvement consultant and thought leader in support of the quality and safety improvement efforts of regional and local leadership.
  • Aligns corporate and local/regional quality and safety improvement efforts with Steward’s overarching strategic plan.
  • Work closely with Risk to review safety events and clinical areas of vulnerabilities.
  • Provides support and partnership to Regulatory leadership to optimize regulatory performance and institutional readiness.
  • Assists the Associate Chief Medical Officer in preparing reports for the team members
  • Guides the facilitation of clinical and operational improvements through appropriate identification and application of personnel, data, improvement methods, and electronic tools.
  • Engages in continuing education in both quality and leadership/management.
  • Promotes the interests of Steward Healthcare Network both intramurally and extramurally.
  • Identifies areas of practice improvement to drive performance beyond current workflows and collaborates with appropriate team members and across Steward’s teams to facilitate and support implementation of such initiatives.
  • Collaborates with data analytics to ensure clinical data quality and accuracy as well as data flow to all quality tools and dashboard through implementation of effective audit and data management practices.
  • Develops and utilizes appropriate project tracking systems and processes to manage the supply and demand of analytic resources.
  • Provide steady and effective mentorship with on-going communication and feedback
  • Provides excellent communication with all customers, interacting with physicians, nursing, financial and operational team members.


(Examples: Ability to work independently and take initiative; Good judgment and problem solving skills; Communication skills; Interpersonal and organizational skills; Level of confidentiality)

  • Work-related achievement in and leadership in Quality and Patient Safety, HRO, Just Culture, TJC/DNV/CMS/AHRQ, and publicly reported data sets such as Leapfrog, HCAHPS and CMS PSI measures.
  • Work-related knowledge and demonstratable success with performance and quality improvement.
  • Work-related knowledge and demonstratable success in managing risk and clinical outcomes.
  • Organizational and project management skills commiserate with the ability to manage complex projects through effective planning, tracking, and resource allocation to meet business objectives and timelines.
  • Excellent verbal and written communication skills and outstanding interpersonal skills; ability to relate positively with individuals at all levels of the organization.
  • Proven leadership and management skills.
  • Ability to mentor and train staff in all aspects of their role.
  • A history of creativity and flexibility as a self-motivated professional with sound judgment.


  1. Education: Master’s Degree in Healthcare or Business Administration, Nursing, Public Health or Related Field of Study from an accredited college or university
  2. Experience (Type & Length): At least five years of experience working in quality, regulatory affairs, performance improvement, medical group management, or medical informatics. Leadership experience in large integrated health systems and/or corporate healthcare setting
  3. Certification/Licensure: Preferred clinical background in Medicine, Nursing or other Allied Health profession
  4. Software/Hardware: MS Office
  5. Other:

Application Instructions

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