PERFORMANCE IMPROVEMENT MANAGER - QA \ PERF IMPROVEMENT

Status: Full Time

Shift: Monday - Friday, 8am-4:30pm

Exempt: Yes

Summary:

The Performance Improvement Manager is responsible for leading and overseeing performance improvement (PI) initiatives across the hospital system. This role drives continuous quality improvement using data-driven methodologies, ensures alignment with strategic priorities, and supports operational leaders in achieving measurable improvements in patient outcomes, safety, experience, and efficiency. The Manager fosters a culture of continuous improvement and coordinates system-wide efforts utilizing Lean, Six Sigma, and other performance improvement frameworks.

Other information:

Education, Licensure and/or Work Experience Requirements:

• Experience Required: Minimum 3-5 years of experience in healthcare performance improvement, quality, operations, or performance improvement related field
• Leadership Experience: Demonstrated experience leading cross-functional teams and managing improvement initiatives
• Education Required: Bachelor's degree in healthcare administration, nursing, public health, business, performance improvement or related field
• Education Preferred: Master's degree (MHA, MPH, MBA, or related field)
• Licensure/Certifications Preferred: Lean Six Sigma Green Belt or Black Belt (or equivalent certification), Project Management Certification
• Skills Required: Strong analytical, problem-solving, and project management skills; proficiency in data analysis and Microsoft Office tools
• Preferred Experience: Experience with hospital operations, quality metrics (HCAHPS, CMS measures), and performance dashboards

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

Responsibilities:

Performance Improvement Leadership

• Lead and coordinate hospital-wide performance improvement initiatives aligned with organizational goals.
• Develop and implement a structured performance improvement framework across all service lines.
• Establish priorities, timelines, and accountability measures for PI initiatives.
• Serve as a subject matter expert in Lean, Six Sigma, PDSA, and other improvement methodologies.

Project Oversight & Execution

• Oversee a portfolio of performance improvement projects across clinical and operational areas.
• Partner with department leaders to identify improvement opportunities and define project scope.
• Ensure consistent use of standard PI tools, methodologies, and documentation.
• Monitor project progress and remove barriers to successful implementation.

Data Analysis & Performance Monitoring

• Analyze performance data, dashboards, and key performance indicators (KPIs) to identify trends and opportunities.
• Develop and maintain system-level reporting for performance improvement efforts.
• Ensure data integrity and effective use of data to drive decision-making.
• Report progress, outcomes, and risks to senior leadership.

Education & Capacity Building

• Develop and deliver training programs on performance improvement methodologies.
• Coach leaders, managers, and frontline staff in PI tools and techniques.
• Build internal capacity for continuous improvement across the organization.

Strategic Alignment & Integration

• Align performance improvement efforts with organizational strategic goals and regulatory requirements.
• Collaborate with Quality, Patient Safety, Infection Prevention, Experience, Population Health, and Regulatory teams to ensure integrated improvement efforts.
• Support initiatives related to patient experience, clinical quality, health equity, and operational efficiency.

Culture of Continuous Improvement

• Promote a culture of accountability, innovation, and continuous improvement.
• Recognize and spread best practices across departments.
• Facilitate multidisciplinary teams to sustain improvements and standardize processes.

Non-Essential Duties and Responsibilities:

• Assist with special projects related to quality, safety, and organizational strategy.

• Support preparation of presentations, reports, and executive summaries for leadership.

• Participate in committees and workgroups as a performance improvement resource.

• Assist with accreditation or regulatory-related improvement activities when needed.

• Contribute to internal communications promoting performance improvement successes.

• Provide backup support for Quality Department initiatives during peak periods.

• Other duties as assigned