Director, Quality & Performance Improvement

Location: Valley Presbyterian Hospital - Van Nuys, CA

We are seeking an experienced and visionary Director of Quality & Performance Improvement to lead our organization-wide quality, patient safety, accreditation, and performance improvement initiatives.

Position Summary

The Director of Quality & Performance Improvement is an inspiring healthcare leader responsible for providing strategic, operational, and thought leadership in support of Valley Presbyterian Hospital's mission and vision.

Reporting as a key member of hospital leadership, the Director collaborates closely with executive leadership, medical staff, clinical department chairs, and operational leaders to develop, implement, and sustain best-in-class quality and performance improvement initiatives.

This leader serves as the organization's authority on patient safety, regulatory readiness, accreditation compliance, quality outcomes, publicly reported quality measures, and performance excellence. The Director oversees the hospital-wide Quality Assessment and Performance Improvement (QAPI) program while fostering a culture of safety, accountability, high reliability, and continuous improvement.

The Director provides operational and clinical improvement expertise through quality analytics, education, physician engagement, regulatory oversight, and multidisciplinary collaboration to improve patient outcomes, enhance the patient experience, and achieve strategic organizational goals.

Essential Responsibilities

The Director will:

• Provide strategic leadership for Valley Presbyterian Hospital's Quality Assessment and Performance Improvement (QAPI) Program.
• Develop, implement, and evaluate the annual Quality Assessment and Performance Improvement Plan and organizational quality goals.
• Lead hospital-wide quality improvement initiatives that improve clinical outcomes, patient safety, operational effectiveness, and patient experience.
• Serve as the organizational lead for regulatory surveys, accreditation activities, and continuous survey readiness, including DNV, CMS, CDPH, and other regulatory agencies.
• Direct organizational responses to regulatory findings and oversee development and implementation of corrective action plans.
• Lead multidisciplinary performance improvement teams utilizing evidence-based improvement methodologies.
• Oversee peer review processes, including OPPE, FPPE, case review, and physician quality initiatives in collaboration with Medical Staff leadership.
• Develop and maintain enterprise quality dashboards, scorecards, performance metrics, and quality reporting systems.
• Analyze quality, safety, operational, and publicly reported performance data to identify trends and develop actionable improvement strategies.
• Monitor organizational performance related to CMS Quality Programs, Value-Based Purchasing, Hospital Compare, Readmissions Reduction Program, Hospital-Acquired Conditions Reduction Program, and other federal and state reporting initiatives.
• Research and implement best practices in quality improvement, patient safety, and healthcare performance.
• Design and deliver organization-wide education related to quality improvement, patient safety, accreditation, and regulatory compliance.
• Prepare and present quality, patient safety, accreditation, and performance reports to Executive Leadership, Medical Executive Committee, Governing Board, Quality Committee, Patient Safety Committee, and other leadership groups.
• Partner with operational and clinical departments to improve performance, quality outcomes, and resource utilization.
• Recruit, develop, mentor, and evaluate Quality Department staff while building a high-performing team.
• Develop departmental budgets, staffing plans, succession planning strategies, and operational goals.
• Perform additional responsibilities and strategic projects as assigned.

Required Qualifications

Experience

• Minimum of five (5) years of progressive acute care hospital experience in quality, patient safety, and performance improvement.
• Demonstrated leadership of hospital-wide Quality Assessment and Performance Improvement (QAPI) programs.
• Experience leading patient safety initiatives, root cause analyses (RCA), corrective action plans, and organizational safety culture programs.
• Experience managing publicly reported quality measures, CMS quality programs, value-based purchasing initiatives, and organizational performance scorecards.
• Experience presenting quality and patient safety information to executive leadership, governing boards, and medical staff committees.
• Experience utilizing quality analytics, benchmarking data, statistical methodologies, dashboards, and data visualization tools.
• Experience leading multidisciplinary teams through complex organizational change initiatives.
• Experience managing peer review, OPPE, FPPE, and physician quality improvement programs.
• Experience leading accreditation readiness and successful regulatory surveys.
• Experience supporting disease-specific certifications and specialty accreditation programs.
• Proven ability to manage multiple complex quality improvement initiatives simultaneously.

Education

Required

• Bachelor's degree in Nursing or another healthcare-related discipline.

Preferred

• Master's degree in Nursing, Healthcare Administration, Public Health, Business Administration, or another related healthcare field.

Licensure & Certifications

Required

• Current California Registered Nurse (RN) license.
• LA City Fire Card certification upon hire or within 30 days of employment.

Preferred

• Certified Professional in Healthcare Quality (CPHQ).
• Lean, Six Sigma, or other recognized performance improvement certification.

Knowledge, Skills & Abilities

The ideal candidate demonstrates:

• Expert knowledge of quality improvement methodologies, Lean principles, patient safety science, and reliability improvement.
• Strong understanding of CMS Conditions of Participation, Joint Commission standards, California regulatory requirements, accreditation processes, and healthcare compliance.
• Knowledge of publicly reported quality measures, value-based reimbursement, and healthcare benchmarking.
• Experience with statistical process control, dashboards, scorecards, and quality analytics.
• Outstanding leadership, project management, and organizational skills.
• Excellent executive communication, presentation, physician engagement, and facilitation abilities.
• Ability to analyze complex clinical and operational data and translate findings into measurable improvement strategies.
• Strong interpersonal skills with the ability to influence leaders across a highly matrixed organization.
• Demonstrated commitment to customer service, collaboration, accountability, and continuous learning.
• Ability to effectively manage competing priorities while maintaining composure under pressure.
• Sound judgment, critical thinking, and exceptional problem-solving skills.

Compliance Requirements

All required licenses, certifications, mandatory education, and occupational health requirements must be maintained in accordance with Valley Presbyterian Hospital policies and regulatory requirements. Employees are responsible for completing all required renewals prior to expiration or within the required compliance timeframe.

If you are a collaborative healthcare quality leader with a passion for driving measurable improvement, patient safety, and organizational excellence, we encourage you to apply.