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Director, Quality Improvement

Eureka, CA, USA | St. Joseph Health

  • Industry:
    Healthcare - Hospitals
  • Position Type:
  • Functions:
    General Management
    Operations / Production
  • Experience:
    5-7 years
Job Description:
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Job Summary:

The Humboldt Director of Clinical Excellence manages and coordinates area wide efforts to ensure that Performance Improvement (PI) activities are developed and managed using a data-driven focus that sets priorities for improvements aligned to ongoing strategic imperatives. 

The Clinical Excellence Director plans, organizes and directs all aspects of the Performance Improvement function including clinical outcomes, infection control, clinical analytics, operational improvements, and organizational regulatory and accreditation readiness. The Director in collaboration with other members of the department provides the organization with focus and education on performance improvement, outcomes reporting, and regulatory issues

Develops and communicates the strategic vision, scope and mission for Clinical Excellence in collaboration with the Chief Medical Officer (CMO), and the Executive Management Team (EMT). Also, assures that organization-wide Clinical Excellence initiatives are focused and aligned on improving operational and program efficiencies and effectiveness; participates in organizational strategic planning and provides leadership for improvement activities, and policy/protocol development and effective implementation plans that leads to reliable/sustainable results.Provides leadership and coordination to develop PI and QI training programs that focus on enabling the workforce to achieve improvements, and assure high reliability processes for sustainability of top benchmark performance.  

The Director in collaboration with other members of the department provides the organization with focus and education on performance improvement, outcomes reporting, and regulatory issues

The Clinical Excellence Director is expected to effectively utilize a scientific approach in the analysis of clinical outcomes while advocating for the patient and family this individual will identify opportunities for improved clinical practice, quality improvement and cost reduction based on the proven science of improvement, current research findings and evidence-based findings.Practice is in accordance with The Joint Commission (TJC) standards, California Department of Public Health (CDPH), Center for Medicare and Medicaid Services (CMS) and all other State and Federal regulatory criteria, and professional practice standards.Proficiency is demonstrated in the required competencies. 

This position requires regular travel to local ministries to lead or coordinate meetings, activities, and resolve issues.

Essential Functions:

A key responsibility is to assure ongoing progress toward SJHS Clinical Excellence Goalsintegrating methodologies to improve clinical qualitywhile assuring compliance with external agencies and regulatory agency standards, integrating information from the Clinical Quality databases, coordinating CMS Partnership for Patients, Premier, IHI, NQF, HCAHPS/PRC and Leapfrog initiatives and other system-wide quality initiatives.  

Internal facilitation of best practicesto achieve and sustainbest practice for best benchmark performance and meet internal and external benchmarks 

The Director is responsible for creating and performing orientation and educational programs in collaboration with regional and system PI experts for a continuous learning system that continues to build ministry capability and capacity for continuous improvement. 

The Director is also responsible for staffing the Quality Committee of the Board for Humboldt ministries and for other committees as requested.This position requires regular travel to local ministries to lead or coordinate meetings, activities, and resolve issues.

Act as an agent on behalf of the best interests of the Humboldt; works to address special needs (e.g., disparities in care, health literacy, and employee safety), values and works to provide support and resources as needed. 

Analytic thinking and knowledge-based decision making:breaks problems down into parts or steps; (workflow) recognizes multiple layers of cause and effect; collects appropriate information to make decisions informed by available evidenced competencies and patient experiences and perspectives; values and supports transparency.

Development of a knowledge-rich environment—supports continuous improvement/learning in the quality of data available to support decision making (collection, record keeping, access) by using emerging technology and methods

Help position the St. Joseph Health System, Humboldt County as the premiere hospital relative to key clinical/patient safety and patient experience outcomes. Examples of activities would include the development of clinical pathways with medical and hospital staff, benchmarking, participation in multi-hospital collaborative, and standardization of care to support adoption and implementation for best documentation and ease of use.

Able to balance competing priorities and balance clinical, operational and financial goals.Able to make a business case for changes in process or product in collaboration with other disciplines so that mutual goals are met or potential consequences for changes requested by Quality and Patient safety are weighed and mitigated in advance.  

PI Program management must include ability to rapidly respond to shifts in regulatory and accreditation requirements or emerging science through a nimble adaptive management style.  

Demonstrates SJH ethics and values and supports integrity in his or her professional conduct; considers the ethical implications of decisions; acts openly and transparently; develops a reputation as trustworthy/reliable

Ensures integration of the Hospital’s quality, financial, operational and strategic planning processes to facilitate house-wide focus and achievement of performance improvement priorities.

Fosters a climate that facilitates clear, fast, open and accurate communication regarding Performance Improvement (PI) and outcomes at all levels of the organization, with the Board of Trustees, Medical Staffs, and with the communities we serve.

Creates an environment where:

Best practices are accomplished through development of data driven strategies and tactics.

Resources are identified, acquired, and are freely shared across/among teams.

Key stakeholders are engaged and accountable for achieving excellent outcomes.

Champions an organizational environment of education, learning, and organizational competencies at all levels using proven principles and tools for continuous assessment and achievement of Performance Improvement tactics and clinical outcomes.

Assures that major decisions related to Performance Improvement and Clinical Quality takes into account their effect on the organization and the communities we serve.

Establishes mutually beneficial partnerships with external consumers (payors, brokers, medical groups, employer groups and other community and patient group contacts) to maximize their awareness of Performance Improvement and Clinical Outcomes activities for the St. Joseph Health.

Collaborates with leaders and staff across the organization, and with other entities and the System office, in pursuit of best practice and effective communication of excellent outcomes to our community.


Proficiency in knowledge of data management, data governance and clinical analytics (internal and external) as well as data presentation. 

Proficient in Microsoft Office 

Excellent organizational skills especially when coordinating big projects, committees and special events, like CEU, CME. 

Idea champion and effective change agent

Strong interpersonal skills to work with all levels of employees, physicians and customers

Ability to create strong business partnerships

Strong facilitation and complex problem-solving skills

Ability to maximize output to multiple deadlines, while maintaining a calm demeanor

Demonstrated excellent verbal, written and presentation communication skills

Expert knowledge of applicable accreditation and regulatory standards

Minimum Position Qualifications:

Education: Master or Doctor level degree

Experience: 5-7 years in Performance Improvement and 3-5 years of increasing responsibility in leadership/oversight of Quality programs. 

Training: Training in performance improvement tools and techniques. Training in change management, team dynamics and facilitation. 

License / Certification: National certification in performance improvement preferred (e.g. Certified Professional in Healthcare Quality –CPHQ preferred)

Preferred Position Qualifications:

Education: Master or Doctor level degree in clinical field (e.g. MSN, PharmD. or equivalent level)


Experience: Experience with system initiatives and/or multi-hospital performance improvement collaborative

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