Director, Quality & Performance Improvement

Baystate Health•Springfield, MA

About The Position

The Director, Quality and Performance Improvement reports to the Vice President, Quality and Safety and serves as a system leader for quality reporting, performance measurement, data analytics, and enterprise performance improvement. In close collaboration with the Director, Quality and Patient Safety, this role ensures alignment between quality performance, patient safety priorities, and regulatory requirements to drive measurable and sustainable improvements in care delivery. This Director leads the development, execution, and sustainment of a high-performing quality infrastructure, including data governance, reporting strategy, performance dashboards, and improvement initiatives. The role is responsible for ensuring data integrity, actionable insights, and standardization of performance improvement methodologies across Baystate Health, enabling leaders to identify variation, reduce risk, and achieve regulatory and organizational goals. The Director integrates clinical quality, patient experience, and nursing-sensitive outcomes into a unified performance framework, advancing high reliability through data-driven decision-making, systems thinking, and evidence-based improvement strategies to translate performance data into meaningful, sustained results in partnership with clinical and operational leaders.

Requirements

Master’s degree (MPH, MHA, MBA, or related field)
Certification in Healthcare Quality or Performance Improvement (CPHQ or equivalent)
Minimum of five (5) years of progressive experience in healthcare quality, performance improvement, or analytics
Demonstrated experience in quality reporting, regulatory programs, and performance measurement systems
Strong analytical, leadership, and change management skills
Strong knowledge of CMS, Joint Commission, and payer-based quality programs
Experience leading large-scale improvement initiatives and interdisciplinary teams

Nice To Haves

Clinical or healthcare-related degree

Responsibilities

Lead the strategy, development, and oversight of enterprise quality reporting, including internal and external metrics (CMS, Joint Commission, DPH, Leapfrog, payer programs).
Ensure accuracy, integrity, validation, and timeliness of clinical quality data submissions and reports.
Oversee development and maintenance of dashboards, scorecards, and visual management tools to support organizational performance transparency.
Translate complex data into actionable insights, identifying trends, variation, and opportunities for improvement.
Partner with informatics and analytics teams to optimize data infrastructure, reporting capabilities, and system integration.
Lead system-wide performance improvement initiatives aligned with organizational priorities, regulatory requirements, and strategic goals.
Standardize and deploy evidence-based improvement methodologies (ex. PDSA, FMEA, Common Cause Analysis) across departments.
Facilitate interdisciplinary improvement efforts to address high-risk or underperforming areas, ensuring measurable outcomes and sustainment.
Monitor improvement plans, ensuring accountability, milestone tracking, and escalation of risks or barriers.
Identify unwarranted variation in clinical and operational performance through data analysis and benchmarking.
Partner with operational leaders to redesign processes, workflows, and care models to improve efficiency, reliability, and outcomes.
Promote system-level thinking, ensuring solutions address root causes and are scalable across the organization.
Support integration of evidence-based practices into workflows and performance expectations.
Partner closely with the Director of Quality and Patient Safety to align performance data with safety event trends, RCA findings, regulatory reporting, and risk mitigation strategies.
Oversee alignment of quality performance metrics with regulatory and accreditation standards (CMS CoPs, TJC, DPH, and payer-based programs), ensuring integration across quality, safety, and operational data.
Support coordinated prioritization of improvement efforts based on risk, performance gaps, and regulatory requirements.
Ensure survey readiness by validating performance metrics, documentation, and outcomes demonstrate compliance and sustained improvement.
Provide interpretation of regulatory requirements as they relate to quality measurement and reporting.
Ensure bidirectional communication between quality reporting and patient safety programs to drive transparency, alignment, and system learning.
Advance High Reliability Organization (HRO) principles using data transparency, standard work, and performance accountability.
Reinforce Just Culture principles by promoting fair and consistent use of performance data to drive improvement rather than punitive action.
Support leaders in using performance data to engage teams, drive ownership, and sustain improvement.
Foster a culture of continuous learning by linking data, outcomes, and improvement actions.
Provide leadership oversight of the Patient Safety Event Reporting System (SRS), serving as system administrator and ensuring adherence to industry standards and best practices.
Ensure effective configuration, data integrity, and optimization of the reporting system to support timely event capture, analysis, and organizational learning.
Leverage internal and external benchmarking to evaluate safety event trends, identify variation, and inform performance improvement priorities.
Ensure alignment and integration of safety event data with quality, patient experience, and nursing-sensitive outcome data to support a comprehensive view of system performance.
Direct and develop Quality & Performance Improvement staff, including data analysts, healthcare quality specialists, and performance improvement specialists.
Build organizational capability in data literacy, performance improvement methodologies, and use of analytics in decision-making.
Establish competencies in quality measurement, data interpretation, and improvement science for department and workforce.
Support workforce planning and alignment with evolving organizational priorities.