This position provides strategic leadership for the organization's quality, patient safety, and performance improvement initiatives while fostering a culture of continuous improvement across the health system.
Reporting to senior leadership, the Director of Performance Improvement partners with administrative leaders, department directors, physicians, providers, and frontline staff to improve clinical outcomes, patient safety, regulatory compliance, and operational performance. This leader provides oversight for Quality, Clinical Risk Management, Infection Prevention, Care Coordination, Utilization Review, and other related performance improvement functions.
The ideal candidate is a respected clinical leader who is comfortable working across departments, facilitating meaningful change, leveraging data to improve outcomes, and supporting leaders in delivering exceptional care to our patients and communities.
Primary Responsibilities- Provide strategic leadership for Cass Health's Performance Improvement program, fostering a culture of continuous quality improvement, patient safety, and organizational excellence.
- Lead and oversee Quality, Clinical Risk Management, Infection Prevention, Care Coordination, Utilization Review, Peer Review, and other related performance improvement functions.
- Serve as Cass Health's Clinical Risk Manager, leading investigations of patient safety events, facilitating debriefings and root cause analyses, identifying trends, and partnering with leaders to implement sustainable improvements.
- Partner with administrative leaders, department directors, medical staff, and frontline teams to improve clinical quality, patient outcomes, operational performance, regulatory compliance, and patient experience.
- Collaborate with the Chief Financial Officer, Revenue Cycle, Care Coordination, medical staff, and clinical leaders to oversee hospital-based utilization review, medical necessity, and documentation improvement activities.
- Partner with Medical Staff leadership and Health Information Management to administer the clinical components of the Medical Staff Peer Review Program and promote physician engagement in quality improvement.
- Oversee the organization's incident reporting and patient grievance processes, ensuring timely investigation, follow-up, regulatory compliance, and organizational learning.
- Utilize data, benchmarking, and evidence-based improvement methodologies to identify opportunities, measure outcomes, and support leaders in achieving departmental and organizational goals.
- Prepare reports and present quality, patient safety, and performance improvement initiatives to senior leadership, Medical Staff committees, and the Board of Trustees.
- Serve as a trusted advisor to organizational leaders by promoting collaboration, accountability, transparency, and continuous improvement throughout Cass Health.
QualificationsRequired
- Bachelor's degree in Nursing, Healthcare Administration, or another healthcare-related field.
- Registered Nurse (RN) or other clinical healthcare background with demonstrated clinical knowledge.
- Certified Professional in Healthcare Quality (CPHQ) certification or the ability to obtain certification within 12 months of hire.
- Previous healthcare leadership experience in quality improvement, patient safety, clinical operations, clinical education, or a related field.
- Working knowledge of healthcare quality improvement methodologies, patient safety principles, accreditation standards, and applicable regulatory requirements.
- Demonstrated leadership, communication, analytical, and relationship-building skills.
Preferred
- Master's degree in Nursing, Healthcare Administration, Business Administration, or a related field.
- Current CPHQ certification.
- Experience in a Critical Access Hospital or rural healthcare environment.
- Experience leading multidisciplinary performance improvement initiatives and organizational change.
