Director, Quality Initiatives & System Improvement

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• Requisition # 2026-187752
• ShiftDay
• StatusFull Time with Benefits

Overview

Our team members are the heart of what makes us better.

At Hackensack Meridian Health we help our patients live better, healthier lives - and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It's also about how we support one another and how we show up for our community.

Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change.

The Director, Quality Initiatives and System Improvement (DQI&SI) provides oversight to all hospital-based work to attain unsurpassed clinical and patient-reported outcomes. The DQI&SI builds organization-wide participation in improvement through transparency, collaboration and mutual learning. The DQI&SI facilitates the redesign of patient care processes, analyzes data to inform and guide improvement efforts, and develops organizational capacity for improvement through teaching and mentorship. While directing the assessment, planning, implementation, monitoring and evaluation of best practices, the MQI&SI ensures that cost effective, quality care is administered to all patients in accordance with the hospital PI plan, while complying with the standards of all regulatory and accrediting agencies. Working in conjunction with, and reporting directly to, the regional Chief Quality Officer, the DQI&SI will provide oversight to all system quality activities by identifying areas for improvement. Provides leadership in the implementation and integration of the Department of Patient Care Performance Improvement Plan in addition to ensuring JCAHO & regulatory compliance. Oversees various activities of the Patient Safety and Quality Department while aligning with the Medical Center and HMH Performance Improvement Plan.

Responsibilities

A day in the life of a Director, Quality Initiatives and System Improvement at Hackensack Meridian Health includes:

• Provides leadership to all quality improvement activities at a hospital including committee meetings, event management, follow up of ONELink event reports, and specific improvement cycles.
• Provides leadership to local HRO transformation. Engages all levels of leadership, caregivers and staff in advancing patient safety through HRO training, morning safety huddles, and integration of principles of high reliability
• Develops and oversees organizational quality initiatives and the monitoring of quality priorities.
• Presents quality data results with analysis and recommendation to a variety of organizational committees and councils including Department of Patient Care to enhance achievement of HMH quality goals.
• Oversees all quality improvement staff and their work in quality councils, teams and committees. Cultivates and promotes continuous learning inside and outside of the network.
• Ensures compliance with all federal and state regulatory and licensing requirements, including aspects of Joint Commission readiness.
• Guide continuous learning and transparency related to quality initiatives. Incorporate continuous learning throughout the network including evidence based best practices and scalable system improvements.
• Guides hospital work in achieving HMH annual and strategic quality goals.
• Ensures use of appropriate methodologies and relevant tools to achieve rapid cycle improvement (i.e. PDSA, FMEA, reliability science, bundle science, process flows).
• Collaborates with the Patient Safety and Quality Department as well as with the VP, Chief Quality/Safety to ensure that organizational wide quality initiatives are implemented effectively
• Ensures effective analysis of performance data with comparison over time and comparisons to internal and external benchmarks to identify improvement opportunities.
• Oversees and facilitates regularly scheduled updates and educational sessions for physician and nursing leaders, managers, and team members throughout the organization so that they are able to use the monthly quality scorecard information and participate in achieving the HMH quality goals.
• Ensures trend analysis is completed and appropriate response to unfavorable trends are developed and deployed.
• Develops and implements action plans based on analysis of data results.
• Supervises the education of staff in regards to relevant performance improvement theories and tools to staff & managers.
• Ensure plans and designs are consistent with internal and external expectations for accreditation, regulatory compliance and public reporting.
• Aligns performance improvement to the Magnet philosophy.
• Responsible for interviewing and hiring Quality staff and managing performance evaluations.
• Assuring all quality staff act in accordance with the Medical Center Code of Conduct.
• Member of the Patient Safety Committee, Performance Improvement Coordinating Committee, Nurse Executive Council, Nursing Operational Committee
• Maintains professional growth and development through seminars, workshops and professional facilitations to maintain and extend expertise of self and team.

Qualifications

Education, Knowledge, Skills and Abilities Required:

• Master''s degree in Nursing, Health Care Administration, Public Health, or other advanced health

related degree

• Minimum of 7 years of clinical experience in an acute care hospital.
• Minimum of 3 years of experience in patient safety and quality.
• Excellent written and verbal communication and presentation skills.
• Proficient computer skills that include but are not limited to Google Suite and/or Microsoft Office

platforms

• Demonstrated leadership abilities.

Education, Knowledge, Skills and Abilities Preferred:

• Performance Improvement expertise
• HRO experience
• Mastery of performance improvement methodologies
• Highly collaborative leader

Licenses and Certifications Required:

• CPHQ (Certified professional in Healthcare Quality) or CPPS (Certified professional in patient safety)

If you feel that the above description speaks directly to your strengths and capabilities, then please apply today!

Compensation

Minimum rate of $156,062.40 Annually

HMH is committed to pay equity and transparency for our team members. The posted rate of pay in this job posting is a reasonable good faith estimate of the minimum base pay for this role at the time of posting in accordance with the New Jersey Pay Transparency Act and does not reflect the full value of our market-competitive total rewards package.

The starting rate of pay is provided for informational purposes only and is not a guarantee of a specific offer. Posted hourly rates may be stated as an annual salary in the offer and posted annual salaries may be stated as an hourly rate in the offer, depending on the level and nature of the job duties and credentials of the candidate. The base compensation determined at the time of the offer may be different than the posted rate of pay based on a number of non-discriminatory factors, including but not limited to:

• Labor Market Data: Compensation is benchmarked against market data to ensure competitiveness.
• Experience: Years of relevant work experience.
• Education and Certifications: Level of education attained, including specialized certifications, credentials, completed apprenticeship programs or advanced training.
• Skills: Demonstrated proficiency in relevant skills and competencies.
• Geographic Location: Cost of living and market rates for the specific location.
• Internal Equity: Compensation is determined in a manner consistent with compensation ranges for similar roles within the organization.
• Budget and Grant Funding: Departmental budgets and any grant funding associated with the job position may impact the pay that can be offered.

Some jobs may also be eligible for performance-based incentives, bonuses, or commissions not reflected in the starting rate. Certain positions may also be eligible for shift differentials for work performed on evening, night, or weekend shifts.

In addition to our compensation for full-time and part-time (20+ hours/week) job positions, HMH offers a comprehensive benefits package, including health, dental, vision, paid leave, tuition reimbursement, and retirement benefits.

HACKENSACK MERIDIAN HEALTH (HMH) IS AN EQUAL OPPORTUNITY EMPLOYER

All qualified applicants will receive consideration for employment without regard to age, race, color, creed, religion, sex, sexual orientation, gender identity or expression, pregnancy, breastfeeding, genetic information, refusal to submit to a genetic test or make available to an employer the results of a genetic test, atypical hereditary cellular or blood trait, national origin, nationality, ancestry, disability, marital status, liability for military service, or status as a protected veteran.

Our Network

Hackensack Meridian Health (HMH) is a Mandatory Influenza Vaccination Facility

As a courtesy to assist you in your job search, we would like to send your resume to other areas of our Hackensack Meridian Health network who may have current openings that fit your skills and experience.

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