Director Quality & Performance Improvement, Saint John's Health Center, Santa Monica

Director Quality and Performance Improvement 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 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 ongoing monitoring of quality and safety data needed to meet accreditation requirements. The Director will develop, monitor and effectively regulate departmental budgets, serve as a catalyst and mentor for motivating productivity, innovation, improvement, high employee morale and commitment to the organization, and may act on behalf of the Quality Executive Director at ministry, regional, and system‑level meetings. What You’ll Do Lead execution of ministry‑specific quality monitoring and performance improvement infrastructure. Facilitate the local adoption of the Performance Improvement process throughout the Ministry acting as a coach and mentor for Ministry, departmental, and unit improvement teams. Identify and prioritize key strategic initiatives to achieve Quality, Safety, Patient Experience, and related service goals. Execute and coordinate innovative strategies with leaders at the system, divisional and local ministry level. Demonstrate sustainable progress on improvement priorities, and monitor & report 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; review mortalities, and other outcomes as needed and coordinate action plans with ministry leadership. In collaboration with the ACOE analytics team, ensure service line leaders have access to actionable and timely data, and oversee internal monthly reporting of key executive clinical institute metrics and quality reporting infrastructure at the ministry and division levels. Analyze, trend, monitor, and present data to core leaders, service line leaders, physicians, etc., and collaborate to drive improvement through developed action plans. Oversee the collection, organization, and submission of outcomes data for different payor designations and programs, e.g., Blue Distinction, Anthem. Oversee the submission and validation of quarterly nurse sensitive indicators to NDNQI and other nursing databases; coordinate with the magnet coordinator to communicate progress to nursing leadership and identify appropriate data for Magnet Sources of Evidence. Evaluate the impact of patient experience performance on CMS, US News, Healthgrades national programs, and provide oversight to development of Performance Improvement plans to improve these rankings. Oversee analytics, validation, and submission in collaboration with ministry leaders for specialty certification designation and various registry or data collection organizations (QHIP, CMQCC, NSQIP, GWTG). Coordinate efforts with divisional data team to ensure all externally reported data are accurate and timely, including review of fallout cases and action plans. Act as hospital’s QNET administrator – upload required outcomes and oversee reporting to Ministry leaders. Demonstrate service excellence and positive interpersonal relations in dealing with others. Ensure standardization and consistency, fostering leadership development in advanced quality performance improvement activities throughout the organization. Collaborate with risk management, patient safety, regulatory, and divisional quality leadership to develop standardized processes and share learnings. Facilitate monitoring and evaluation of PI/patient safety activities using identified quality indicators, maintaining confidentiality of all information related to patients, staff, employees, and other information. Assist in the orientation and ongoing education and mentoring of leaders and caregivers in the PI process in collaboration with regional PI team. Supervise the collection, assessment, and presentation of information to facilitate ongoing measurement of processes and outcomes. Assist as necessary in data collection for key quality performance indicators. Develop systems and processes to assure reliability, accuracy, and confidentiality of information used in departmental functions. Work collaboratively with Risk Management, Patient Safety, Regulatory, and Infection Prevention on the integration of risk, patient safety, quality improvement and regulatory compliance. Collaborate with the Executive Director of Quality to support Medical Staff leadership in developing and implementing systems and processes to identify practice variations and opportunities for improvement. Collaborate with the Executive Director of Quality using divisional PI resources to provide PI support to the organization. Work collaboratively with Ministry Regulatory Program, physician, operational and clinical leaders to ensure ongoing survey readiness. Provide comprehensive reports of quality performance improvement activities to PI teams, applicable Medical Staff committees, organization boards, and Community Ministry Board. Serve as a coach and mentor to direct reports. Maintain 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 education/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. Demonstrate expertise in healthcare data analytics and performance improvement methodology, with the ability to take complex data sets, effectively mine data, and provide actionable insights to drive quality improvement activities. Requisition ID 440499 Job Details Company: Providence Jobs Job Category: Clinical Quality Job Function: Quality/Process Improvements Job Schedule: Full time Job Shift: Day Career Track: Leadership Department: 7006 PSJHC QUALITY ASSURE Address: CA Santa Monica 2121 Santa Monica Blvd Work Location: Providence Saint John’s Health Ctr‑Santa Monica Workplace Type: On‑site Pay Range: $74.17 - $117.10 per hour (base pay; additional compensation may be available) #J-18808-Ljbffr Providence