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Calling all Esteemed Leaders! Are you a quality and performance improvement leader who excels at translating data into action, driving measurable outcomes, and advancing a culture of continuous improvement? Do you thrive in highly collaborative environments where quality, safety, patient experience, and regulatory excellence are critical to organizational success? This leadership opportunity invites your expertise.

 

The Role: 

Under the direction of the Executive Director Quality, the Director Quality and Performance Improvement will be responsible for planning, designing, directing, and executing performance improvement work in alignment with the Value Triple Aim (Quality, Service and Cost Excellence).

The Director will partner with Ministry physician, clinical, and operational leaders to develop the infrastructure, reporting mechanisms and strategies to facilitate Performance Improvement and achievement of Providence system, divisional, and ministry-specific goals and strategic initiatives.

The Director will ensure the proper preparation and coordination of resources needed to achieve regulatory compliance related to the CMS COP Quality Assessment and Performance Improvement (QAPI) Plan and QAPI Annual Evaluation, and The Joint Commission standards, Co-chair the Quality Patient Safety Committee related to performance improvement, to include the collection, analyses, reporting and on-going monitoring of quality and safety data needed to meet accreditation requirements.

The Director Quality and Performance Improvement develops, monitors and effectively regulates departmental budgets. Serves as a catalyst and mentor for motivating productivity, innovation, improvement, high employee morale and commitment to the organization.

The Director Quality and Performance Improvement may act on behalf of the Quality Executive Director at ministry, regional, and system-level meetings.

 

What You'll Do:

• Leads execution of ministry-specific quality monitoring and performance improvement infrastructure.
• Facilitates the local adoption of the Performance Improvement process throughout the Ministry acting as a coach and mentor for Ministry, departmental, and unit improvement teams.
• Identifies and prioritizes key strategic initiatives to achieve Quality, Safety, Patient Experience, related service goals.
• Executes and coordinates innovative strategies with leaders at the system, divisional and local ministry level.
• Demonstrates sustainable progress on improvement priorities, and monitors & reports ministry progress to executive leadership, Medical staff, and Governing body.
• Act as primary resource to Clinical Institute/Service Line leaders to provide and/or interpret data for decision making including clinical outcomes, LOS, payment data from payors, and physician outcomes. Reviews mortalities, and other outcomes as needed and coordinates action plans with ministry leadership (CMO, CNO, department leadership, & Quality Executive Director).
• In collaboration with the ACOE analytics team, ensures service line clinical institute leaders are knowledgeable and have access to actionable and timely data and oversight internal monthly reporting of key executive clinical institute metrics and are engaged in quality reporting infrastructure at the ministry and division levels.
• Responsible for analyzing, trending, monitoring, and presenting data to core leaders, service line leaders, physicians, etc. and collaborating to drive improvement through developed action plans.
• Oversees the collection, organization, and submission of outcomes data for different payor designations and programs, e.g., Blue Distinction, Anthem, etc.
• Oversees the submission and validation of quarterly nurse sensitive indicators to NDNQI and other nursing databases. Utilizes the clinical, operational and/or cost outcome reports, trends, and coordinates with the magnet coordinator to communicate progress to nursing leadership. In collaboration with Magnet coordinator routinely identifies appropriate data for Magnet Sources of Evidence.
• Evaluates the impact of patient experience performance to CMS, US News, Healthgrades national programs. Provides oversight to development of Performance Improvement plan to improve these national rankings via departmental performance improvement projects tied to key patient experience metrics.
• Oversight of data analytics, validation, and submission in collaboration with ministry specific leaders for specialty certification designation and various registry or data collection organizations (QHIP, CMQCC, NSQIP, GWTG, etc.).
• Coordinate efforts with divisional data team to ensure all externally reported data are accurate and comprehensive at the time of reporting, including the review of fallout cases, and coordinating action plans as needed. Strategic oversight of organizational performance that is externally reported, ensuring escalation, leadership awareness and performance improvement strategies are implemented (e.g., insurance payor quality metrics, CMS, national quality registries).
• Act as hospital’s QNET administrator – upload required outcomes, i.e., CDAC validation outcomes. Oversight of download measure outcomes, PEPPER reports, Preview reports etc., and ensure process for review and dissemination to Ministry leaders, as appropriate.
• Demonstrates service excellence and positive interpersonal relations in dealing with others.
• Assures the standardization, consistency, and fosters development in leaders for advanced quality performance improvement activities throughout the organization.
• Works collaboratively with risk management, patient safety, regulatory, and divisional quality leadership to develop standardized processes and share learnings throughout the ministry, division, and Providence system.
• Facilitates the monitoring and evaluation of PI/patient safety activities using identified quality indicators, and maintains confidentiality of all information related to patients, medical staff, employees, and as appropriate, other information.
• Assists in the orientation and ongoing education and mentoring of leaders and caregivers in the quality performance improvement process in collaboration with regional PI team.
• Supervises the collection, assessment and presentation of information to facilitate the ongoing measurement of processes and outcomes.
• Assists, as necessary, in the collection of data for key quality performance indicators.
• Develops systems and processes to assure the reliability, accuracy and confidentiality of information used in the department functions.
• Works collaboratively with Risk Management, Patient Safety, Regulatory, and Infection Prevention on the integration of risk, patient safety, quality improvement and regulatory compliance.
• Collaborates with the Executive Director of Quality to support Medical Staff leadership in the development and implementation of systems and processes to identify practice variations and opportunities for improvements in patient care processes and/or outcomes for the organization.
• Collaborates with the Executive Director of Quality drawing on performance improvement resources and methodology from the divisional teams to provide PI support to the organization.
• Works collaboratively with the Ministry Regulatory Program, physician, operational and clinical leaders to ensure ongoing survey readiness.
• Provides comprehensive reports of quality performance improvement activities to PI teams, applicable Medical Staff committees, organization boards, and the Community Ministry Board.
• Serves as a coach and mentor to direct reports.
• Maintains professional growth and development through participation in seminars, educational programs, workshops, and professional affiliations.

 

What You’ll Bring:

Education & Credentials

• Bachelor's Degree in Health-related field; or equivalent educ/experience

• Master's Degree in Business or Health-related field (preferred)

• Preferred within 1 year of hire: Certified Professional in Healthcare Quality (CPHQ)

Experience & Expertise

• 5 years of experience in an Acute care setting practicing within quality, performance improvement, and data analytics.

• 8 years of Progressive hospital leadership positions (preferred)

Professional & Technical Capabilities

• Demonstrate a working knowledge of national healthcare trends in quality improvement and management.

• Working knowledge of The Joint Commission standards and/or regulatory agency requirements regarding PI/Quality.

• Work efficiently and effectively in a matrix structured environment.

• Understand the needs and preferences of customers served.

• Strong presentation and interpersonal skills that display a presence of leadership in a wide range of settings.

Skills:

• Quality and Safety.

• Driving improvement.

• Risk Assessment.

• Conflict Resolution.

• Staff Development.

• Interpersonal Communication.

• Must be organized, detail oriented, and savvy working with data, statistics, and project management methodologies.

• Efficiently problem solve, while dealing with a diverse set of systems and individuals.

• Developing and motivating staff to their highest potential, using strong leadership skills and interpersonal communication skills.

• Requires significant discretion and knowledge of department to prioritize work load.

• Respond to multiple duties simultaneously.

• Demonstrates expertise in healthcare data analytics and performance improvement methodology, with the ability to take complex data sets, effectively data mine, and through analysis identify pertinent insights an interpretation providing actionable insights to drive quality improvement activities.

 

Why Join Us?

• Quality Leadership: Drive performance improvement initiatives that directly impact quality, safety, patient experience, and organizational outcomes. 

• Strategic Influence: Partner with physicians, executives, operational leaders, and governing bodies to advance ministry and system priorities. 

• Data-Driven Impact: Leverage analytics, reporting, and benchmarking to identify opportunities and deliver measurable improvement. 

• Regulatory Excellence: Lead efforts supporting accreditation, QAPI compliance, survey readiness, and external reporting programs. 

• Mission‑Driven Work: Support high-quality, patient-centered care through continuous improvement and a culture of excellence.

 

Ready to Shape the Future of Healthcare?

If you are a collaborative, data-driven quality leader with a passion for performance improvement, patient safety, and organizational excellence, we encourage you to apply.

The full pay range is listed in accordance with applicable law. Final compensation will be determined based on qualifications, experience, organizational compensation alignment, and the approved hiring department budget for the position. This position may also be eligible for incentive compensation and benefits.

The Sisters of Providence and Sisters of St. Joseph of Orange have deep roots in California, bringing health care and education to communities from the redwood forests to the beach shores of Orange county - and everywhere in between. In Southern California, Providence provides care throughout Los Angeles County, Orange County, High Desert and beyond.

Our award-winning and comprehensive medical centers are known for outstanding programs in cancer, cardiology, neurosciences, orthopedics, women's services, emergency and trauma care, pediatrics and neonatal intensive care. Our not-for-profit network provides a full spectrum of care with leading-edge diagnostics and treatment, outpatient health centers, physician groups and clinics, numerous outreach programs, and hospice and home care, and even our own Providence High School.

Providence is proud to be an Equal Opportunity Employer. We are committed to the principle that every workforce member has the right to work in surroundings that are free from all forms of unlawful discrimination and harassment on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law. We believe diversity makes us stronger, so we are dedicated to shaping an inclusive workforce, learning from each other, and creating equal opportunities for advancement.