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? The Role Under the direction of the Executive Director Quality, you will plan, design, direct, and execute performance improvement work aligned with the Value Triple Aim (Quality, Service and Cost Excellence). You will partner with Ministry physician, clinical, and operational leaders to develop infrastructure, reporting mechanisms, and strategies that facilitate performance improvement and achieve Providence system, divisional, and ministry‑specific goals and strategic initiatives. You will coordinate resources for regulatory compliance (CMS COP QAPI Plan, QAPI Annual Evaluation, Joint Commission standards) and co‑chair the Quality Patient Safety Committee to collect, analyze, report, and monitor quality and safety data to meet accreditation requirements. You will develop, monitor, and regulate departmental budgets and mentor teams for productivity, innovation, and high employee morale. What You'll Do Lead execution of ministry‑specific quality monitoring and performance improvement infrastructure. Facilitate local adoption of the performance improvement process across the Ministry, coaching and mentoring improvement teams. Identify and prioritize key strategic initiatives for quality, safety, patient experience, and service goals. Execute and coordinate innovative strategies with leaders at system, divisional and local ministry levels. Demonstrate sustainable progress on improvement priorities and report ministry progress to executive leadership, medical staff, and governing body. Act as primary resource to Clinical Institute/Service Line leaders, providing or interpreting data for decision‑making. Collaborate with the ACOE analytics team to ensure access to actionable data and oversee internal monthly reporting of executive clinical institute metrics. Analyze, trend, monitor, and present data to leaders, fostering improvement through action plans. Oversee collection, organization, and submission of outcomes data for payor programs. Validate and submit quarterly nurse‑sensitive indicators to NDNQI and nursing databases. Evaluate patient experience performance impact on CMS, US News, Healthgrades, and develop plans to improve rankings. Coordinate data analytics for specialty certification and registry programs (QHIP, CMQCC, NSQIP, GWTG). Ensure external reporting accuracy and coordinate action plans for breakout cases. Act as QNET administrator for required outcomes uploads and review. Demonstrate service excellence and foster leadership in quality performance improvement activities. Collaborate with risk management, patient safety, regulatory, and division leadership to standardize processes. Monitor and evaluate PI/patient safety activities using identified quality indicators. Orient and mentor leaders and caregivers in the quality performance improvement process. Supervise presentation of data to support ongoing measurement of processes and outcomes. Develop systems to assure reliability, accuracy, and confidentiality of information. Work with risk management, patient safety, regulatory, and infection prevention to integrate risk, safety, quality improvement and compliance. Collaborate with the Executive Director of Quality to support Medical Staff leadership in process improvement. Collaborate with Ministry Regulatory Program and other leaders to maintain survey readiness. Report quality performance improvement activities to PI teams, committees, boards, and community ministry board. Coach and mentor direct reports. Maintain professional growth through participation in educational activities. What You'll Bring Education & Credentials Bachelor’s Degree in a health‑related field or equivalent education/experience. Master’s Degree in business or health‑related field (preferred). Within 1 year of hire, Certified Professional in Healthcare Quality (CPHQ) preferred. Experience & Expertise 5 years in an acute‑care setting practicing quality, performance improvement, and data analytics. 8 years of progressive hospital leadership positions (preferred). Professional & Technical Capabilities Working knowledge of national healthcare quality improvement trends. Knowledge of The Joint Commission standards and regulatory agency requirements for PI/Quality. Efficiently works in a matrix‑structured environment. Understanding of customer needs and preferences. Strong presentation and interpersonal skills for leadership. Skills Quality and safety. Driving improvement. Risk assessment. Conflict resolution. Staff development.Interpersonal communication. Organized, detail‑oriented, data‑savvy with project management methodology. Problem‑solving across diverse systems. Motivating staff and prioritizing workload with discretion. Responding to multiple duties simultaneously. Analytics expertise to mine data and provide actionable insights. Benefits Lead performance improvement initiatives that directly impact quality, safety, patient experience, and organizational outcomes. Partner with physicians, executives, and governing bodies to advance priorities. Leverage analytics, reporting, and benchmarking to deliver measurable improvement. Support accreditation, QAPI compliance, survey readiness, and external reporting programs. Contribute to high‑quality, patient‑centered care through continuous improvement and a culture of excellence. Equal Opportunity Employer 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. We believe diversity makes us stronger, and we are dedicated to shaping an inclusive workforce and creating equal opportunities for advancement. #J-18808-Ljbffr Providence Health & Services