Summary:
The Quality and Performance Improvement Director is responsible for understanding existing and emerging requirements in health care quality, safety, service, and operations improvement. In collaboration with leadership, this role develops quality and performance improvement (PI) structures across the system to meet organizational performance needs and goals, ensuring compliance with the philosophy, policies, procedures, goals, and budget of the organization. The Director oversees daily operations and workflow of the Performance Management Department and participates in linking process improvement with technology capabilities.

Essential Duties and Responsibilities:

· Lead all aspects of NOMC Quality and Performance Improvement Programs in compliance with Joint Commission standards, CMS Conditions of Participation, and state licensing laws.

· Prepare annual Performance Improvement Plans and Appraisals for NOMC in collaboration with leadership and committees.

· Facilitate annual development of system-wide priorities for quality and performance improvement.

· Assist departments in developing annual Plans of Care/Service aligned with system goals.

· Assist with coordinating activities of the Quality Outcomes and Patient Safety Committee; serve as the Chair of the Performance Improvement Committee.

· Organize major performance improvement initiatives based on public measures, quality/safety data, financial data, and patient satisfaction data.

· Develop and maintain the organizational balanced scorecard for quality, safety, satisfaction, and efficiency, report key metrics to committees and boards.

· Coordinate training programs on performance improvement methodologies, including orientations and advanced training in alignment with performance improvement programs led by the CQHEO.

· Use feedback from employees and medical staff to improve program effectiveness.

· Develop and implement recognition activities and communication strategies related to performance improvement efforts.

· Assure department policies and procedures are developed and implemented.

· Prepare annual department budget and monitor monthly variances.

· Hold regular meetings with CQHEO and staff to review progress.

· Prepare annual department goals and monitor achievement.

· Address staff development through education, coaching, counseling, and evaluations.

· Maintain professional growth through meetings, seminars, and participation in state/national activities.

· Follow North Oaks Health System compliance programs and regulatory guidelines.

· Assist in reviewing new services according to New Service Protocol.

· Ensure accuracy and timeliness of external quality and patient experience reporting; maintain data integrity and compliance with reporting requirements.

· Collaborate with IS department to ensure data integrity and streamline data abstraction/reporting.

· Serve as administrator for quality software solutions.

· Monitor healthcare trends and proactively respond with interventions. 

· Collaborate with CQHEO to forecast financial needs and coach others on performance improvement tools.

· Manage department operations within approved policies and budget; ensure timely completion of projects and documentation accuracy.

· Collaborate on clinical informatics projects to advance patient safety, quality, and workflow efficiency.

· Perform other duties as assigned by CQHEO.

Non-Essential Duties and Responsibilities:

· Participate in community outreach or organizational events as a representative of the Performance Management Department.

· Assist other departments with performance improvement projects outside of primary scope when requested.

· Serve on internal committees or task forces unrelated to core job duties to support organizational initiatives.

· Provide occasional support for accreditation preparation activities beyond assigned responsibilities.

· Contribute to staff and quality division engagement activities.

· Assist with special projects or research initiatives as assigned by leadership.

· Offer mentorship or informal coaching to staff members outside the department when appropriate.

· Support organizational communication efforts by contributing content for newsletters or intranet updates.

Education, Licensure and/or Work Experience Requirements:

· Experience Required: 3 years of experience in quality and or performance improvement.

· Previous Experience Required: Minimum 5 years of professional- level clinical experience in health care, with supervisory experience preferred.

· Education Required:

· Minimum Bachelor of Science in Nursing

· Licensure/Certifications Required: Active RN License

· Education Preferred:

· Preferred master’s degree in healthcare field.

· Licensure/Certifications Preferred:

· CPHQ credential preferred (must attain within two years of hire).

· Lean Six Sigma certification preferred (must attain within first year of hire).

Physical Requirements and Work Environment:

· Ability to safely and successfully perform the essential job functions consistent with the ADA, FMLA and other federal, state and local standards, including meeting qualitative and/or quantitative productivity standards.

· Physical Demands: (occasionally, frequently, constantly or SLMHV)

o Strength: occasionally

o Push: occasionally

o Pull: occasionally

o Carry: occasionally

o Lift: occasionally

o Sit: occasionally

o Stand: occasionally

o Walk: occasionally