Job Abstract

The Executive Administrator serves as a highly visible organizational champion of quality, patient safety and high reliability. This position is responsible for clinical quality improvement efforts, clinical regulatory activities and accreditation, support of medical staff peer review and performance improvement within Keck Medical Center of USC. This position reports directly to the Chief Medical Officer (CMO) and collaborates closely with hospital leadership, clinical departments, and quality improvement teams to drive initiatives aimed at enhancing patient care, safety, and satisfaction with the goal of achieving world class clinical and patient-centered outcomes that set the standard in healthcare delivery and innovation. This leader is also 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 registrations, 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 work flow efficacy and efficiency, increase cost effectiveness ensure high patient satisfaction and outstanding performance on key, nationally standardized metrics of quality and safety.

The Executive Administrator provides administrative and operational oversight, development and implementation of organization-wide strategies for quality Improvement, patient safety, clinical performance improvement, clinical regulatory compliance, accreditation compliance, and medical staff peer review. The Executive Administrator will identify, evaluate, mitigate and monitor the Quality Outcome's budget to meet organizational needs. This position will facilitate the identification of quality management trends across the organization and will be collaborate with key stakeholders to optimize data collection, reporting, strategy and management required to build an integrated organizational approach to achieving world class performance . Key Responsibilities: Strategic Leadership: Develop and implement organization-wide strategies for quality improvement, patient safety, and clinical performance enhancement. Partner with hospital and medical staff to define strategic direction in reducing clinical errors, enhancing accountability, and promoting a culture of error recognition and improvement. Monitor and develop strategic initiatives to ensure preeminent performance on publicly reported quality and ranking programs. Regulatory, Accreditation and Patient Safety: Identify, evaluate, mitigate, and monitor operational risks related to quality outcomes and regulatory compliance. Ensure adherence to accreditation standards set forth by regulatory bodies such as the Joint Commission (TJC), CDPH, CMS and other licensing, accreditation authorities. Quality Management and Performance Improvement: Facilitate the identification of quality management trends and collaborate with key stakeholders to optimize data collection, reporting, and management. Lead initiatives to improve patient care management, clinical outcomes, workflow efficiency, and cost-effectiveness. Facilitate and coordinate medical staff peer review functions Regulatory Compliance and Reporting: Verify compliance with all quality and risk-related requirements, registrations, communications, and reporting obligations to regulatory bodies. Ensure successful performance on facility-specific quality measures and nationally standardized metrics of quality and safety. Stakeholder Collaboration: Collaborate with medical staff, department leaders and interdisciplinary teams to implement evidence-based practices and drive quality improvement initiatives. Collaborate with key stakeholders to meet value based program goals and requirements including commercial payer and CMS. Collaborate with Risk Management and Compliance Department to ensure error identification, investigation and mitigation. Foster a collaborative environment that promotes engagement and participation in quality and safety initiatives across the organization.

Essential Duties:

• The initial priorities of this position are to: • Become fully integrated into and be seen as a trusted and contributing member of Keck’s leadership team by building credibility with leadership through expertise and a collaborative style. • Improve the rankings in all publically reported quality metrics. • Conduct an assessment of the Quality and Outcomes Department and make recommendations for improvements. • Continue to design structure and automate fluid and rigorous processes, systems and infrastructure that lead to higher efficiency and quality departmental work.
• Primary leadership and direction for creating the infrastructure and resources to support the organization’s quality strategy and programs.
• In conjunction with other medical center executives including the CMO, physician leaders, and staff, the AEDQ develops strategy, designs projects and processes to ensure both methodological and operational integrity. Participate and support organizational committees, teams, and projects for the hospital related to all aspects of performance improvement and the optimization of patient outcomes.
• Excellence in Service and Clinical Quality • Develops and implements service standards to meet patient and other customer definitions of excellence. • Promotes the reduction of errors and improves systems and processes by searching for the root causes of events, working collaboratively with nursing, professional and administrative staff members, focusing on patient safety and developing key strategies to reduce liability exposure. • Identifies through the review of events, problems, patterns and trends that reflect opportunities for prevention and improvement. • 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. • Facilitates risk control activities (e.g. Root Cause Analysis) and risk assessments (e.g. Failure Mode Effect Analysis) throughout the department to reduce the number, severity and cost of losses. • 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. Serves in an active role in the event review and reporting process. • Fosters and maintains collaborative relationships with external agencies, purchasers, and stakeholders related to quality/performance initiatives. • Reviews all incidents and events recommending corrective action and monitors effectiveness of actions and countermeasures. • Reviews and evaluates services of Keck Medicine 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 Medicine of USC leadership and medical staff regarding regulatory issues, new statutes/guidelines and medical safety/PI and high reliability activities. • Provides risk management education for the leadership team, professional staff and employees concerning methods for decreasing risk. • Provides training/ mentoring staff to promote patient safety and reduce liability loss. • 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. • Manages the electronic incident reporting system and ensures that events are identified, addressed, trended and analyzed. Performance improvement opportunities are identified and facilitated. • 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. • Evaluates new and existing department services and procedures to determine if they present risk to the organization and assists with countermeasures to improve the service in cooperation with the Risk Management department. • 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. • Participates in routine rounds in all clinical areas in collaboration with the Nursing department to identify and remediate areas of risk. • Promotes the reduction of healthcare errors and improves systems and processes by searching for the root causes of events, working collaboratively with nursing, professional and administrative staff members, focusing on patient safety and developing key strategies to reduce liability exposure. • 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 • Collaborates with executive staff and other directors to understand external market financial, economic, and industry data, identifying market opportunities and threats from a quality stand point. • 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, taking into account 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. • Responsible for the development of a data strategy that informs key leadership and the Governing Board of an integrated picture of Quality Outcomes Interprets metrics to identify trends related to Patient Safety/QA to support proactive identification and monitoring. • Responsible for leading data management and analysis of Patient Safety and QA Metrics.
• 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. • Responsible for the management of Quality Outcomes Budget and ensures resource utilization in cost effective manner.
• 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. • Maintains current knowledge of applicable State and Federal regulations. Ensures policies and procedures are in compliance with applicable State and Federal regulations. Collaborates with Risk Management and other department(s) to coordinate the investigation of events that could give rise to legal liability. • Performs other duties as assigned.

Required Qualifications:

• Bachelor's degree in Nursing preferred; other healthcare related field
• Master's degree in a healthcare related field

• 5 years 5 to 10 years' experience in hospital management with recent performance improvement experience including survey experience.
• 5 years Progressive leadership experience as an administrator in an acute care environment managing, leading, and developing staff.
• Experience in leading Quality Improvement Programs as well as expertise in working with risk management and accrediting organizations.

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

Preferred Qualifications:

• Certification - Job Relevant Additional certification and/or training in healthcare quality or equivalent

Required Licenses/Certifications:

• Registered Nurse - RN (CA Board of Registered Nursing) OR; Other clinical license.
• 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)
• Certified Professional in Healthcare Quality - CPHQ (NAHQ) CPHQ certification required; if not certified must achieve certification within 6 months of hire.

USC is an equal opportunity, affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, disability, or any other characteristic protected by law or USC policy. USC will consider for employment all qualified applicants with criminal histories in a manner consistent with the requirements of the Los Angeles Fair Chance Initiative for Hiring ordinance. We provide reasonable accommodations to applicants and employees with disabilities. Applicants with questions about access or requiring a reasonable accommodation for any part of the application or hiring process should contact USC Human Resources by phone at (213) 821-8100, or by email at uschr@usc.edu.  Inquiries will be treated as confidential to the extent permitted by law.

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