Job Summary:
Provides strategic leadership to advance organizational excellence in clinical quality, safety, and operational performance across all hospitals, markets, and service lines. Establishes enterprise-wide structures, governance frameworks, and accountability mechanisms to ensure consistent deployment of evidence-based improvement methodologies, with the goal of achieving top-decile national performance, eliminating preventable harm, and driving sustainable financial results. Serves as a key member of the senior leadership team, partnering directly with the C-suite, Board Quality Committee, System CMOs, System CNOs, and market presidents to set strategic direction, align improvement priorities, and build a culture of high reliability and continuous improvement. By driving breakthrough performance in mortality, readmissions, hospital-acquired conditions, patient safety indicators, and patient experience, this role directly impacts organizational reputation, market position, and financial sustainability through optimized reimbursement, reduced penalties, and eliminated waste.
Job Requirements:
Education and Work Experience:
- Master's degree in Health Care Administration, Nursing, Public Health, Medicine or equivalent combination of education/related experience: Required
- Seven years' health care or related experience: Required
- Five years' leadership experience in quality, patient safety, performance improvement, or healthcare administration: Required
Licenses/Certifications:
- CPHQ or CPPS or Six Sigma Green Belt or Lean Certification: Required within two years of hire
- Clinical Background: Required
- Certified Professional in Healthcare Quality (CPHQ) or Lean or Six Sigma Green Belt (LGB): Required
Essential Functions:
- Serves as the leader for quality and performance improvement strategy, partnering directly with the Quality & safety Executive, CEO, CMO, CNO, and Board Quality Committee. Provides expert consultation and executive briefings on quality performance, national benchmarks, competitive positioning, and strategic implications. Leads development of the organization's multi-year quality strategic plan with measurable goals tied to financial and operational targets. Represents the organization externally with regulators, payers, and national quality organizations.
- Directs enterprise-wide programs that drive top-decile performance in mortality, readmissions, LOS, HACs, PSIs, and patient experience. Oversees strategy deployment for value-based purchasing, pay-for-performance, and quality-based contracts - ensuring maximum reimbursement and penalty avoidance. Leads adoption of evidence-based practices and clinical pathways that improve outcomes while reducing total cost of care. Accountable for achieving and sustaining national recognition (Leapfrog A ratings, Vizient top quartile, CMS 5-star).
- Leads the deployment and sustainment of Lean, Six Sigma, and other performance improvement methodologies across hospitals and service lines. Establishes structures, processes, and accountability systems for consistent PI across the organization. Oversees large-scale improvement initiatives that drive measurable results in patient outcomes, operational efficiency, and financial performance.
- Builds and leads a high-performing team of Directors, Managers, and quality professionals across the system. Mentors and develops Network Directors of Quality and Patient Safety, strengthening leadership bench and succession pipeline. Creates and delivers executive education programs on quality, safety, and PI for senior leaders and physician executives. Fosters a learning organization culture with best practice sharing, communities of practice, and innovation incubation.
- Ensures robust systems for accurate, timely collection and analysis of clinical outcomes and PI data. Directs development of executive dashboards, and predictive analytics that link quality performance to financial outcomes. Benchmarks against national standards and competitors; identify strategic opportunities and risks. Partners with CFO and Finance to quantify ROI of quality initiatives, project penalty exposure, and optimize quality-based revenue. Accountable for quality-related financial performance including value-based contract performance, penalty avoidance, and cost reduction.
- Performs other job-related duties as assigned.
