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

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 k