System AVP, Acute Care Quality and Data Management

System Assistant Vice President for Acute Care Quality and Clinical Data Management

The System Assistant Vice President for Acute Care Quality and Clinical Data Management provides strategic system level leadership to translate and leverage data for consistent improvement in quality, patient safety, and operational performance across all business units. Applies advanced understanding of data analytics to recommend changes to processes, procedures, and policies to ensure safety, quality, and clinical excellence are consistently achieved across multiple hospitals/institutes. Additionally, this role holds functional accountability as a business partner for the overall quality program across multiple hospitals and institutes, ensuring that patient safety, quality, and clinical excellence are consistently achieved. Reporting to the Vice President of Acute Care Quality, this leader regularly partners with executive leaders and clinical, operational, and business intelligence teams to address problems that are significant and complex. The leader applies advanced understanding of data management to standardize processes, reduce variability, and foster a proactive culture of safety and continuous improvement, empowering staff at all levels to engage in improvement initiatives and contribute to a culture of learning. Collaborating closely with executive leaders and clinical teams, this leader ensures alignment with national benchmarks and regulatory standards.

Position Highlights:

• Position: System AVP, Acute Care Quality and Clinical Data Management

• Hourly Pay Range: $79.81 - $120.19. The hourly pay rate offered is determined by a candidate's expertise and years of experience, among other factors.

• Location: Evanston, IL or Warrenville, IL

• Full Time/Part Time: Full Time

• Hours: Monday-Friday, during normal business hours

• Required Travel: frequent travel to other Endeavor Health locations will be required

What you will do:

• Quality Business Partner Hospital(s)/Institutes (50%)

  • Supports business unit to achieve quality/patient safety outcomes, management planning and integration from a system perspective.

  • Applies advanced understanding of improvement and change management to partner with clinical, operational, and hospital/institute leaders accountable for quality, regulatory compliance, and patient safety.

  • Sets strategy with executive level leadership to solve for defects in care identified through safety-related incidents, near-misses, sentinel events and other sources of data.

  • Make decisions and recommendations to address clinical quality problems that are highly varied and significantly complex identifying areas for advance and sustain improvement.

  • Applies advanced knowledge of improvement science to partner with teams leading to optimal performance in CMS, Leapfrog, Joint Commission, and other agencies.

  • Ensures adherence to and assists in the achievement of clinical performance outcomes utilizing a collaborative process that focuses on the use of best practices and measurable outcomes.

  • Cultivates a just culture and staff engagement and well-being by promoting a culture of joy and retention.

• System Level Functions (50%)

  • Routinely communicates with executive leaders to provide strategic and operational direction for system-improvement based on data, inclusive of resources, infrastructure, program creation and deployment, benchmarking, data analytics, and communications.

  • Analyzes data from multiple sources and creates system level improvement plans ensuring alignment with regulatory compliance, risk management, and public reporting requirements (e.g., CMS, Leapfrog, VBP).

  • Serves as a strategic thought partner for system leaders, translating complex analytics into actionable insights to prioritize quality, safety, and operational improvements.

  • Leads partnership efforts to integrate clinical, financial, and operational quality data into data warehouses, unified dashboards and reports that provide real-time visibility into performance metrics.

  • Creates proactive risk management strategies through data collaborating with key stakeholders, risk management, infection prevention, and patient safety to use predictive analytics for early detection of potential issues.

  • Establishes a centralized approach to quality data reporting, analysis, and dissemination across the system, ensuring alignment of clinical, operational, and quality measures with best practices and national standards.

  • Leads centralized data abstraction team and identifies data-based improvement initiatives ensuring alignment with system priorities and quality improvement goals.

  • Identifies data driven insights from RLDatix ensuring consistent and reliable data capture, data visualization, and system-wide reporting solutions, ensuring initiatives are aligned with strategic objectives.

What you will need:

• Education: Master's degree in nursing, healthcare administration, public health, or a related field required.

• Certification:

  • Certification as a Certified Professional in Healthcare Quality (CPHQ), Certified Professional in Patient Safety (CPPS) or equivalent certification (preferred).

  • Lean Six Sigma or similar performance improvement certification (preferred).

  • High-Reliability Organization (HRO) training or certification (preferred).

• Experience:

  • 7 years of progressive leadership experience in healthcare quality, patient safety, or risk management.

  • 3 years of direct experience as a director.

  • Demonstrated success in leading data initiatives across a multi-hospital health system or integrated healthcare setting.

  • Experience working with The Joint Commission (TJC), CMS, Leapfrog, and other regulatory bodies to ensure compliance and readiness.

  • Proven ability to implement high-reliability principles and foster a culture of safety and continuous learning.

  • Extensive experience in performance improvement methodologies such as PDSA, RCA, FMEA, and ACA.

• Unique or Preferred Skills:

  • In-depth understanding of clinical quality, patient safety, risk management, and regulatory compliance in acute care settings.

  • Expertise in data analytics and performance monitoring tools (e.g., Vizient, RL Solutions, Culture of Safety Surveys).

  • Experience partnering with disciplines in developing dashboards, scorecards, and data visualizations to monitor trends and guide decision-making.

  • Ability to track, trend, and interpret safety metrics and implement corrective actions using data-driven insights.

  • Proven ability to collaborate with executive leaders (CNOs, CMOs, Presidents) and workgroups to align system and hospital-based priorities.

  • Ability to foster cross-disciplinary teamwork to achieve quality outcomes.

  • Experience leading teams to ensure clinical excellence and accountability.

  • Ability to engage frontline staff through safety huddles, leadership walk-arounds, and shared learning initiatives.

  • Expertise with a Clinical Database, reporting systems, classification tools, and root cause analysis processes.

  • Skilled in using heatmaps and scorecards to prioritize risks and guide decision-making.

Benefits (For full time or part time positions):

• Eligibility for our Annual Incentive Plan, which offers the potential to earn a certain percentage amount of your base salary based on organizationalperformance.

• Career Pathways to Promote Professional Growth and Development

• Various Medical, Dental, Pet and Vision options

• Tuition Reimbursement

• Free Parking

• Wellness Program Savings Plan

• Health Savings Account Options

• Retirement Options with Company Match

• Paid Time Off and Holiday Pay

• Community Involvement Opportunities

Endeavor Health is a fully integrated healthcare delivery system committed to providing access to quality, vibrant, community-connected care, serving an area of more than 4.2 million residents across six northeast Illinois counties. Our more than 25,000 team members and more than 6,000 physicians aim to deliver transformative patient experiences and expert care close to home across more than 300 ambulatory locations and eight acute care hospitals - Edward (Naperville), Elmhurst, Evanston, Glenbrook (Glenview), Highland Park, Northwest Community (Arlington Heights) Skokie and Swedish (Chicago) - all recognized as Magnet hospitals for nursing excellence. For more information, visit www.endeavorhealth.org.

When you work for Endeavor Health, you will be part of an organization that encourages its employees to achieve career goals and maximize their professional potential.

Please explore our website (www.endeavorhealth.org) to better understand how Endeavor Health delivers on its mission to "help everyone in our communities be their best".

Endeavor Health is committed to working with and providing reasonable accommodation to individuals with disabilities. Please refer to the main career page for more information.

Diversity, equity and inclusion is at the core of who we are; being there for our patients and each other with compassion, respect and empathy. We believe that our strength resides in our differences and in connecting our best to provide community-connected healthcare for all.

EOE: Race/Color/Sex/Sexual Orientation/ Gender Identity/Religion/National Origin/Disability/Vets, VEVRRA Federal Contractor.