SUMMARY:
The Director, Enterprise Quality, Data Analytics & Performance Improvement provides strategic and operational leadership for the health system's enterprise quality measurement, clinical data analytics, regulatory quality reporting, benchmarking, and performance improvement infrastructure. This leader ensures that accurate, timely, and actionable information is available to executives, boards, physicians, nursing leaders, and operational teams to improve clinical outcomes, meet external reporting requirements, and advance organizational quality priorities.
The Director leads a multidisciplinary team responsible for quality data abstraction and validation, dashboard and scorecard development, performance analysis, improvement consultation, and reporting governance. Working closely with Information Technology, Business Intelligence, Clinical Informatics, Finance, medical staff, and operational leaders, the Director translates complex data into clear insights and supports disciplined improvement across the health system.
ESSENTIAL FUNCTIONS:
ENTERPRISE QUALITY STRATEGY:
• Translate organizational strategy into an enterprise quality measurement and performance improvement agenda.
• Establish annual quality analytics and improvement priorities aligned with governance, clinical, operational, and regulatory needs.
• Advise executives and operational leaders on performance trends, risks, improvement opportunities, and resource priorities.
• Create standardized methods for defining, monitoring, escalating, and closing quality performance gaps.
QUALITY DATA ANALYTICS AND MEASUREMENT:
• Oversee collection, abstraction, validation, analysis, interpretation, and reporting of clinical quality data.
• Establish consistent measure definitions, data specifications, validation controls, and documentation standards.
• Lead benchmarking and comparative performance analysis using appropriate internal and external data sources.
• Develop analytic approaches that identify variation, emerging trends, performance gaps, and opportunities for improvement.
• Ensure analytic products are accurate, reproducible, understandable, and aligned with the intended decision and goals.
DASHBOARDS, SCORECARDS AND EXECUTIVE REPORTING:
• Lead development and maintenance of enterprise quality dashboards, scorecards, and committee reports.
• Present actionable clinical quality findings to executive leadership, boards, medical staff, and operational teams.
• Partner with Business Intelligence and Information Technology to improve data integration, visualization, automation, and reporting reliability.
• Maintain an organized reporting calendar with clear ownership, review expectations, and escalation pathways.
REGULATORY AND EXTERNAL QUALITY REPORTING:
• Oversee compliant and timely submission of required quality data to applicable regulatory, accreditation, payer, and public-reporting programs.
• Monitor changes in measure specifications and reporting requirements and coordinate operational readiness.
• Ensure source documentation, abstraction processes, validation activities, and submission records support data integrity and audit readiness.
• Collaborate with Regulatory and Accreditation leaders on quality-measure readiness and response activities.
PERFORMANCE IMPROVEMENT LEADERSHIP:
• Direct an enterprise performance improvement support model using standardized PDCA methodology and other evidence-based improvement approaches as indicated.
• Assign and prioritize improvement consultants based on strategic need, performance risk, and organizational capacity.
• Ensure improvement projects include clear aims, measures, interventions, accountability, and sustainment plans.
• Coach leaders and teams in interpreting data, identifying root causes, testing change, and evaluating results.
DATA GOVERNANCE AND TECHNOLOGY PARTNERSHIP:
• Partner with Information Technology, Business Intelligence, and Clinical Informatics to define data requirements and improve system interfaces.
• Establish governance for quality data definitions, access, validation, change control, and appropriate use.
• Support documentation and workflow improvements that strengthen measure performance and data reliability.
• Evaluate analytic platforms, contracts, and tools for business value, usability, interoperability, and alignment with enterprise standards.
PEOPLE, PROGRAM AND RESOURCE LEADERSHIP:
• Recruit, develop, and retain a high-performing team with clear roles, competencies, performance expectations, and development plans.
• Set priorities, allocate work, monitor deliverables, and create an environment of accountability, collaboration, and continuous learning.
• Manage assigned budgets, vendor relationships, contracts, programs, and information systems.
• Promote succession planning and cross-training to sustain critical reporting and analytic functions.
GOVERNANCE AND COLLABORATION:
• Support the Quality Leadership Committee and operational councils with accurate and decision-ready information.
• Facilitate alignment among quality, safety, risk, regulatory, clinical, and operational stakeholders.
• Communicate complex findings clearly to technical and nontechnical audiences.
• Maintain confidentiality and appropriate stewardship of clinical, operational, and workforce information.
• Adheres to TMCH organizational and department-specific safety, confidentiality, values, policies, and standards.
• Performs related duties as assigned.
MINIMUM QUALIFICATIONS
EDUCATION:
• Bachelor of Science in Nursing or equivalent required.
• Master's degree in Healthcare Administration, Nursing, Public Health, Health Informatics, Data Analytics, Quality, Business Administration, or a related field preferred.
EXPERIENCE:
• Five (5) years of progressive experience in healthcare quality, clinical analytics, performance improvement, informatics, or related functions required.
• Three (3) years of leadership experience managing people, programs, or departments required.
• Demonstrated experience with healthcare quality measurement, external reporting, dashboard development, data validation, and executive presentation required.
• Experience in an acute care hospital or integrated health system preferred.
• Experience leading enterprise change and cross-functional performance improvement preferred.
LICENSURE OR CERTIFICATION:
• Certified Professional in Healthcare Quality (CPHQ) required or within 12 months of hire.
• Certified Professional in Patient Safety (CPPS) preferred.
KNOWLEDGE, SKILLS AND ABILITIES:
• Advanced knowledge of healthcare quality measurement, clinical outcomes, regulatory reporting, benchmarking, data governance, and performance improvement.
• Strong understanding of data standards, system interfaces, validation methods, dashboard design, and analytic interpretation.
• Ability to translate complex clinical and technical information into concise, actionable recommendations.
• Demonstrated skill in executive communication, facilitation, project portfolio management, change leadership, and staff development.
• Ability to define problems, collect and evaluate data, establish facts, draw valid conclusions, and make sound recommendations.
• Ability to manage competing priorities, sensitive information, vendor relationships, budgets, and critical deadlines with independent judgment.
