Job Requirements Job SummaryProvides strategic and operational leadership for quality improvement initiatives. Leads a portfolio of complex, hospital-wide initiatives focused on improving patient outcomes, regulatory compliance, operational performance, and financial stewardship. Partners with leadership, physicians, nurses, ancillary departments, and frontline teams to identify priorities, implement evidence-based interventions, and sustain measurable improvement. Supervises and mentors staff while serving as an expert consultant in quality improvement, high reliability, and regulatory readiness. Drives achievement of organizational goals, pay-for-performance programs, patient safety indicators (PSIs), mortality, hospital-acquired conditions, and other strategic priorities.
Primary ResponsibilitiesThe following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job responsibilities performed.
- Lead and direct complex, multi-disciplinary quality improvement initiatives across both the Downtown and Midtown Campuses, ensuring alignment with organizational strategy, Annual Operating Plan (AOP) priorities, and the Quality Assurance and Performance Improvement (QAPI) program.
- Provide direct leadership, coaching, and oversight for Quality Improvement staff, including assigning work, developing staff capabilities, monitoring performance, and ensuring timely completion of high-priority strategic initiatives.
- Partner with executive leaders, department chairs, physician leaders, nursing leaders, and operational teams to identify, prioritize, and implement high-impact strategies that improve patient outcomes, patient safety, operational performance, and financial stewardship.
- Analyze, interpret, and synthesize clinical, operational, financial, and regulatory data to identify trends, performance gaps, and opportunities for improvement across service lines and campuses, with responsibility for the hospital's performance in PSIs, mortality, hospital-acquired complications, Vizient, state pay-for-performance programs, and other strategic measures.
- Design, facilitate, and sustain multidisciplinary improvement teams using advanced performance improvement methodologies, including Lean, Six Sigma, Root Cause Analysis, Failure Modes and Effects Analysis, and Plan-Do-Study-Act cycles to achieve measurable and sustainable results.
- Collaborate on, implement, and monitor enterprise dashboards, scorecards, clinical practice guidelines, standardized workflows, corrective action plans, and executive-level reports to support accountability, reduce variation, and improve organizational performance, and communicate progress to senior leadership, medical staff committees, and governing bodies.
- Collaborate with regulatory, accreditation, and operational leaders to ensure ongoing readiness for surveys by The Joint Commission, Centers for Medicare & Medicaid Services, and other external agencies.
- Lead special projects and strategic initiatives that have significant organizational impact, including initiatives involving multiple departments, campuses, or external partners.
- Represent the organization on internal and external committees, collaboratives, and professional forums, and prepare and deliver executive-level presentations, business cases, and recommendations that influence organizational strategy and decision-making.
- Perform all other duties as assigned.
Work Experience Education & Experience - Required- Master's degree in Nursing, Healthcare Administration, Business, or related field.
- Current, active, unrestricted healthcare professional license, registration, or certification in a related discipline and recognized by the applicable state regulatory authority.
- Six (6) years of progressive experience performing quality improvement activities including development of new initiatives.
- Three (3) years of previous supervisory experience managing people and teams.
- Certified Professional in Healthcare Quality (CPHQ) certification.
Education & Experience - Preferred- Experience within an academic medical center, multi-campus health system, or tertiary/quaternary care environment.
- Lean Six Sigma Green Belt, Black Belt, or equivalent process improvement certification
- Experience with quality-based reimbursement programs (e.g. Vizient), patient safety indicators (PSIs), hospital-acquired condition reduction programs, and other external benchmarking or pay-for-performance programs.
Knowledge, Skills, & Abilities- Demonstrated experience partnering with physicians, executives, and interdisciplinary leaders to achieve measurable quality, patient safety, operational, and financial outcomes.
- Expert knowledge of quality improvement, performance improvement, patient safety, and high-reliability principles, including Lean, Six Sigma, Root Cause Analysis, Failure Modes and Effects Analysis, statistical process control, and project management methodologies within a complex healthcare environment.
- Demonstrated ability to lead large, complex, and highly visible initiatives involving multiple stakeholders, competing priorities, and significant organizational impact.
- Strong leadership skills with demonstrated ability to coach, mentor, develop, and hold staff accountable while fostering engagement, collaboration, succession planning, and professional growth.
- Advanced knowledge of patient safety science, event investigation, culture of safety principles, and risk reduction strategies.
- Exceptional communication, facilitation, and presentation skills with the ability to effectively engage and influence executives, physicians, board members, frontline staff, and external stakeholders.
- Ability to influence without direct authority and build collaborative relationships across departments, disciplines, and campuses.
- Advanced analytical skills with the ability to interpret and translate complex clinical, financial, operational, and benchmarking data into actionable insights that drive decision-making and performance improvement.
- Demonstrated ability to manage multiple priorities, meet deadlines, and achieve results in a fast-paced, highly matrixed environment.
- Strong strategic thinking and business acumen, including the ability to align quality initiatives with organizational goals, operational performance, and financial outcomes.
- Advanced knowledge of accreditation, regulatory, and compliance requirements, including The Joint Commission, CMS, state regulatory agencies, and quality reporting programs, with responsibility for survey readiness and compliance oversight.
- Proficiency in Microsoft Office applications and experience using electronic health records (e.g., Epic) and data visualization, reporting, and analytics tools such as Tableau, Power BI, or similar systems.
- Ability to maintain confidentiality, exercise sound judgment, and manage sensitive or high-risk situations with professionalism and discretion.
