Kettering Health is a not-for-profit system of 13 medical centers and more than 120 outpatient facilities serving southwest Ohio. We are committed to transforming the health care experience with high-quality care for every stage of life. Our service-oriented mission is in action every day, whether it’s by providing care in our facilities, training the next generation of health care professionals, or serving others through international outreach.

JOB SUMMARY:
Provides focused leadership for Clinical Quality and Patient Safety across the system to ensure delivery of the
right care, to the right patient, at the right time. Ensures KHN alignment of workflows and performance
improvement initiatives to create one best practice based on national standards.
Responsible for the Quality Programs related Inpatient and outpatient care. Serves as a dyad partner with the
System Patient Safety Officer to develop and implement strategies for a comprehensive Patient Safety
Program including identification and deployment of best practices and a measurement system to monitor
performance. Serves as the System Point of contact for the Patient Safety Organization.
Provides strategy and oversight for management of mandated data reporting requirements including CMS,
Cardiac Registries (STS Adult Cardiac Surgery, NCDR PCI, ICD, Peripheral Vascular, Atrial Fib Ablation, Left Atrial
Appendage Occlusion and STS/ACC Transcatheter Valve Replacement and Repair procedure), and stroke.
Develops strategy and oversight of plans and data management related to infection control and as well as
data management related to requirements for National Healthcare Safety Network (NHSN).
Creates strategies and workflows that support achievement of top decile performance in quality and patient
safety measures related to publicly reported entities and payer scorecards including Anthem, UHC, Top 100,
and healthgrades. Responsible for strategy and deployment of the System’s approach to accreditation for hospitals including
HFAP accreditation and other accrediting/certification and accrediting requirements. Serves as the lead for the
Quality Section of HFAP. Oversees the annual QAPI plan and Patient Safety Plan. Oversees and facilitates the
System peer review process. As part of the multidisciplinary team, this Executive Director collaborates with the quality leadership across the system and other organization leaders to support system wide quality objectives and goals.

JOB REQUIREMENTS
Minimum Education:
• Bachelor’s Degree in nursing
• Master’s Degree in Nursing or Healthcare Related Field
• Certified Professional of Healthcare Quality – required or must be willing to obtain within 3 years
Minimum Work Experience
• Five (5) years of progressive supervisory experience with demonstrated leadership and management skills
• Maintains competencies & skills of specialty area of practice. Ability to communicate effectively, written and
oral.

Required Licenses:

Registered Nurse
• Licensed as a Registered Nurse by the State of Ohio
• Certified Professional of Healthcare Quality – required or must be willing to obtain within 3 years Required Skills
• Skills of specialty area of practice
• Ability to communicate effectively, written and oral

ESSENTIAL FUNCTIONS:
Provides System leadership on strategic quality and patient safety strategies and performance, leading to Top
decile performance.
2. Monitors performance against payers and publicly reported entities to identify key priorities. Including but
not limited to Leapfrog, Top 100, Anthem, UHC, VBP, HAC reduction)
3. Develops strategy and provides guidance and support to the Infection Control Program across KHN.
4. Develop strategic plans for department, utilizing continuous quality improvement process in development
of goals and action plans.
5. Oversight of development and monitoring of key metrics to ensure compliance with National Quality
Initiatives, registries and required reporting.
6. Ensures timely submission of data to meet System obligations for mandatory reporting requirements.
7. Utilizes data to identify priorities to support achieving top decile performance
8. Oversight of System approach for HFAP and other regulatory/accreditation requirements to ensure full
accreditation of each hospital and service.
9. Serves as the lead for the HFAP quality requirements including chapter owner, QAPI review and plan, and
Network Patient Safety Plan.
10. Serves as System Administrator for multiple programs both internal and external including: Quality Net,
NHSN, Cardiac Care and the Patient Safety Organization.
11. Serves as co-chair and facilitator for the System Infection Control Steering Committees.
12. Collaborates with KHN Clinical Quality campus leadership to align processes and deployment of quality
improvement initiatives to achieve One Best Practice.
13. Develop, monitors and guide Clinical Outcomes Department with annual plans and budget management
14. Demonstrates current knowledge of and ability to operationalize nationally recognized quality initiatives,
trends and issues related to areas of responsibility.
15. Actively participates in meetings across network to support performance improvement activities and
initiatives. Serves as facilitator when appropriate.
16. Demonstrates competency through the successful completion of job specific requirements including
analytical, problem solving and conflict resolution skills.
17. Provides oversight support to the campus directors / department managers for Infection Prevention and
Control and Patient Safety.
18. Develop and monitor the Network approach for peer review.
19. Collaborate with Service Line leaders to align and develop quality metrics for employed physicians and
practices.
20. Create an environment of participation and collaboration along with effective communication with key
internal and external stakeholders.

LEADERSHIP CAPABILITIES:
1. Develop annual budget in partnership with finance
2. Ability to develop and present effective and engaging presentations for various audiences
3. Effectively lead and manage direct and indirect reports
4. Effectively build skillsets of direct and indirect reports
5. Effective mentorship of others in the organization
6. Professional and effective collaboration with multiple service lines in the organization and externally with
various community services and health care delivery partnerships

ORGANIZATIONAL EXPECTATIONS:
New Hire/Competencies
1. Applies medical ethics to healthcare relationships
2. Practices the Five Healing Presence Practices
3. Demonstrates Infection control Behaviors