Executive Director, Professional Practice & Nursing Excellence

About City of Hope

City of Hope, an innovative biomedical research, treatment and educational institution with over 6,000 employees, is dedicated to the prevention and cure of cancer and other life-threatening diseases and guided by a compassionate, patient-centered philosophy.

Founded in 1913 and headquartered in Duarte, California, City of Hope is a remarkable non-profit institution, where compassion and advanced care go hand-in-hand with excellence in clinical and scientific research. City of Hope is a National Cancer Institute designated Comprehensive Cancer Center and a founding member of the National Comprehensive Cancer Network, an alliance of the nation's leading cancer centers that develops and institutes standards of care for cancer treatment.

Position Summary

The Executive Director, Professional Practice and Nursing Excellence leads nursing efforts across all inpatient, outpatient and community settings in establishing an environment that supports the delivery of high quality, exquisite patient care. The Executive Director supports the Chief Nursing Officer and is accountable for areas of responsibility that encompass inter-professional practice and health system transformation; professional development; and quality improvement with a focus on improving outcomes. The Executive Director serves as a role model for leadership in the professional practice of nursing. She/he promotes an awareness and understanding of positive professional practice principles, cultivates and inspires transformational leadership principles, and ensures quality staff and patient outcomes through the development of programs and systems consistent with the Mission, vision, values, and strategic plan of the City of Hope Enterprise.

The Executive Director will be responsible for providing leadership and for being a change agent to advance professional practice across the City of Hope Enterprise. This includes establishing partnerships, linkages, and collaboration among inter-professional clinical staff and leaders, as well as affiliated academic institutions and professional organizations. The Executive Director will advance a culture of professional & inter-professional practice, foster evidence-based practices and continuous improvement, cultivate lifelong learning, partner in the implementation and enhance technology to support clinical practice, and service excellence within the City of Hope.

The Executive Director leads a commitment to high quality care as defined by internal and external customers in a way that makes quality knowable and measurable. She/he works to ensure a shared sense of purpose in creating both value for the customer and the committed involvement of nursing staff at all levels. The Executive Director provides focus on the inadequacies of work processes as a source of error, trains others in quality improvement strategies and techniques, and develops an infrastructure to give nursing staff access to the problem-solving process, removing barriers to quality, and offering freedom from fear of reprisal. The Executive Director supports the PDCA model of quality improvement and works with senior leadership to integrate annual quality goals of the City of Hope enterprise and key result areas with quality improvement/safety initiatives within nursing units and departments. She/he partners with physicians, hospital executives, and leadership and managers to execute key performance improvement strategies.

The Executive Director is responsible for oversight and direction Magnet designation program across the City of Hope enterprise. She/he maintains expert knowledge of current Magnet requirements and ensures organization awareness and success and is responsible for coordinating all aspects of the ANCC Magnet application, annual reports and re-designation processes.

The Executive Director is responsible for coordinating and integrating professional practice and nursing excellence activities with other departments and serves as a role model, resource and mentor for patient care staff through support and active participation in the City of Hope Nursing Shared Governance Councils. She/he coordinates activities required to achieve, maintain and sustain ANCC Magnet Recognition Status, including but not limited to providing education to nurses/staff on Magnet Recognition Program standards and expectations, submitting application for Magnet Recognition, verifying that all requirements are met and designing and implementing process to maintain and sustain Magnet worthy level of professional practice and excellence.

Key Responsibilities include:

This role performs in support of the professional practice model and adherence to the Board of Registered Nurse's Scope of Practice, Regulation #2725 for the State of California, the California Nurse Practice Act, Title 22 and the Joint Commission Standards in addition to California licensing requirements as they pertain to this role. This role has the degree of independence required to achieve operating results consistent with approved operating plans, objectives, and policies. The Executive Director of Professional Practice and Nursing Excellence is responsible for the overall operations of her/his departments, including frequent engagement and collaboration with the Medical Staff, compliance with all regulatory agencies (DHS, FACT, TJC, TITLE 22, etc.) for all areas of responsibility. This position must have the ability to engage and influence physicians, staff, and leadership through the use of effective communication and data driven decision making. This position must be familiar with the three (3) collective bargaining agreements representing the employee's e.g. SEIU/UHW; CNA; and Local 30.


  • Responsible for departments' goal development, planning, execution and evaluation of goal achievement. Develops short, mid and long-term Professional Practice and Nursing Excellence goals with plans to facilitate/guide goal achievement that are consistent with the mission and values of the City of Hope and the overall nursing department. Involves unit staff in goal development, planning, execution and evaluation via our shared. Revises plan based upon evaluation of progress toward goals. Assists areas within department with goal development, planning, execution and evaluation. Submits annual report.
  • Effectively communicates with patients, visitors, management staff, departmental personnel, physicians, peers and other City of Hope personnel. Participates in area meetings. Rounds off shift in areas. Demonstrates effective problem solving, negotiating, and conflict resolution skills. Promotes teamwork.
  • Serves as role model, motivates, mentors, and inspires management staff and department personnel; demonstrates flexibility and impartiality when dealing with others. Participates in interviews, hiring, and evaluation of related staff. Serves in the mentor role for the City of Hope Nursing Excellence Council.
  • Participates in and assumes leadership role in City of Hope committees, task forces and special projects. Demonstrates dependability in meeting target dates for reports and project completion. Represents the City of Hope in professional and civic activities locally, across the state or nationally as requested. Remains up-to-date in current level of practice.
  • Develops, implements and evaluates programs with emphasis on improvement in outcomes, service, operations and cost.
  • Facilitates development, implementation and enculturation of City of Hope Professional Practice Model and care delivery system.

Internal Professional Practice/Quality Consultant
  • Communicates the mission, vision and goals of City of Hope Nursing in all interactions with nursing personnel and other disciplines/departments.
  • Fosters collegial professional relationships within nursing service and across hospital departments.
  • Partners with leaders in other patient care disciplines to promote quality patient care.
  • Designs, delivers and evaluates educational programming to support quality, safety, and nursing practice initiatives.
  • Integrates evidence-based patient safety principles in all clinical practice initiatives.
  • Fosters a culture of safety. Encourages reporting of events and near misses.
  • Participates through leadership role modeling in FEMA and root cause analyses.
  • Leads and evaluates nursing initiatives to refine systems and processes to promote patient/nurse safety.
  • Develops, administrates and evaluates framework for the nursing quality improvement program, including data collection and analysis processes, report generation, process improvement, benchmarking, and outcomes management.
  • Provides direction and coordination of quality assessment and improvement initiatives within all nursing units
  • Integrates professional standards and evidence-based practice in development and evaluation of quality and professional practice initiatives.
  • Ensures that performance data is disseminated and activity reviewed for opportunities to change practice.
  • Serves as a resource expert in educating nursing about professional practice and quality improvement.
  • Facilitates City of Hope's participation in the National Database of Nursing Excellence Indicators.
  • Participates in external benchmarking as determined by the organization.
  • Ensures the professional practice and quality improvement programs are congruent with the City of Hope mission and goals.
  • Collaborates with the City of Hope Vice President for Excellence and staff to communicate and coordinate Excellence improvement functions and projects
  • Establishes and maintains collegial relationships with nursing and Excellence professionals across the campus, affiliated Colleges of Nursing and NCI CCC hospitals
  • Provides leadership for nursing involvement in interdisciplinary Excellence improvement initiatives.

Magnet Program Recognition
  • Facilitates and oversees the preparation of documentation, policies, research and informal sessions relative to achieving and maintaining Magnet status.
  • Oversees collection of key nursing sensitive indicators and outcomes and develops all reports and demographics for submission to the ANCC Magnet Office.
  • Serves as a liaison, role model resource and leader of programs/services/committees as needed to further the efforts of the Magnet Recognition Program
  • Oversees all aspects of Magnet® designation and re-designation and other nursing care recognitions, including application, document writing, submission, the appraisal process, and interim reporting.
  • In consultation with other nursing leaders, uses data to develop and implement strategies that promote the quality, safety, efficiency, and effectiveness of professional nursing practice.
  • The manager communicates and educates nursing staff, leaders and organizational stakeholders regarding initiatives and steps to achieve and maintain Magnet® designation.
  • Leads change efforts in collaboration with nurse leaders and staff utilizing the ANCC Magnet framework of excellence to create and implement innovative staff engagement, systems and processes.

Fiscal Management
  • Acts in a fiscally responsible manner
  • Develops revenue growth and effective expense management strategies, inclusive of management of capital and human resources.

Personnel Management & Development
  • Recruit, develop, train and retain needed staff. Provide leadership and mentoring to develop accountable staff.
  • Motivate, influence and foster culture change with staff, colleagues, peers, physicians, other department directors and stake holders in the organization to support the mission and core values.
  • Performs annual employee performance evaluation and motivates employees to perform in an efficient and professional manner; recruits and maintain the staff necessary to carry out the functions of the departments.

Basic education, experience and skills required for consideration:
  • MSN required
  • 8 to 10 years nursing experience required with a minimum of 5 years in nursing leadership. Experience in leading an organization to Magnet Recognition. Knowledge of Quality Improvement activities
  • Proven track record of strategic programmatic leadership.
  • Knowledge of Title 22, DHS, and JCHO standards
  • Must have Excellent Interpersonal skills, must have the ability to effectively influence and persuade nursing, physician, and hospital leadership to implement change.

Required Certification/Licensure:
  • California RN license will be required. National Certification required.

Preferred education experience and skills:
  • Quality Certification recommended.

City of Hope is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, sexual orientation, gender identity, age, status as a protected veteran, or status as a qualified individual with disability.

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