Manager, Performance Improvement-Clinical Quality

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Job Summary

Summary:

The Manager Clinical Performance Improvement (MCPI) provides overall leadership, vision and direction of the Clinical Performance Improvement Department within the Quality Division. This position ensures the appropriate planning, implementation and monitoring of clinical performance improvement activities. The Manager Clinical Performance Improvement works collaboratively with appropriate stakeholders to ensure that all organizational and regulatory agency requirements are met.

Job Responsibilities

• Leads the daily operations of the Clinical Performance Improvement Department and establishes Performance Improvement priorities for the team and in conjunction with other Grady leadership initiatives.
• Manages the completion of the mortality review for the organization.
• Cultivates strong working relationships with Nursing and the Chiefs of Service to ensure quality/performance improvement efforts are identified, resourced, and supported. Directs the service-based performance improvement efforts through focused and generic reviews of services and High Volume (HV), High Risk (HR), Problem Prone (PP), and High Complications (HC) cases.
• Develops, manages and controls budgetary requirements for team success.
• Creates policy and procedures that support Performance Improvement activities.
• Coordinates clinical care standardization through protocols, order sets or process improvement activities.
• Abstracts, submits and identifies performance improvement efforts associated with Centers for Medicare and Medicaid Services (CMS) and the Joint Commission Core Measures (ORYX) as needed.
• Serves as the data resource, in collaboration with the Manager of Clinical Quality Analytics, for clinical performance improvement activities and the distribution, reporting and coordination of activities associated with said improvement efforts.
• Works effectively with other divisions and departments in driving positive quality improvements.
• Demonstrates strong initiative in carrying out assignments and meeting deadlines.
• Promotes open communication, respect, and positive interactions with all levels of staff within the hospital and is a positive role model.

Qualifications:

• Bachelor's Degree in Nursing.
• Master's Degree in Public Health, Hospital Administration, Business Administration or related field preferred.
• 5 years of hospital-based performance improvement, quality assurance, or utilization management experience.
• 3 years of experience in leadership/management role. Experience with chart abstracted quality measures for CMS and TJC required.
• Quality certification.

Core Competencies
These competencies reflect the values and behaviors expected of all Grady team members, regardless of role. They ensure that every employee contributes to safe, high-quality care, positive patient experience, and a collaborative work environment.

1. Patient-Centered Care – Demonstrates a commitment to delivering safe, compassionate, and high-quality care that prioritizes the well-being and satisfaction of patients and their families.
2. Integrity & Accountability – Acts ethically, maintains confidentiality, and accepts responsibility for actions, decisions, and outcomes.
3. Collaboration & Teamwork – Builds positive relationships, works effectively across departments, and supports colleagues to achieve shared goals.
4. Communication – Communicates clearly, respectfully, and effectively with patients, families, colleagues, and leadership.
5. Respect & Inclusion – Creates an inclusive environment by valuing diversity, treating others with dignity, and ensuring equitable care and opportunities for all.
6. Quality & Safety – Adheres to best practices, regulatory standards, and policies to ensure safe, reliable, and high-quality outcomes.
7. Adaptability & Resilience – Responds effectively to change, remains flexible in dynamic situations, and demonstrates resilience under pressure.
8. Continuous Improvement – Seeks opportunities to improve processes, skills, and outcomes through innovation, learning, and feedback.
9. Leadership & Professionalism – Inspires, guides, and develops individuals and teams while modeling professionalism, fairness, and transparency.
10. Employee Experience Focus – Champions a supportive and engaging employee journey that enables staff to thrive and,