System Director of Quality and Performance Improvement (Post-Acute)

Appalachian Regional Healthcare • Lexington, KY

1d

About The Position

The Director of Quality and Performance Improvement is responsible for leading the hospital system's strategic and operational efforts to ensure safe, effective, patient-centered care through continuous quality improvement, regulatory compliance, and performance excellence. This role maintains a specific focus on Long Term Acute Care Hospitals (LTACH), Outpatient Ambulatory Clinics, and Home Health services. This role collaboratively supports these post-acute and ambulatory service lines in the development, implementation, and evaluation of quality and safety programs, performance improvement initiatives, and data-driven decision-making frameworks that align with national standards, accreditation requirements, and organizational goals. The Director collaborates with clinical and administrative leaders to foster a culture of accountability, transparency, and innovation, driving measurable improvements in patient outcomes, service delivery, and organizational efficiency across the continuum of care (clinic to home).

Requirements

• Master’s degree in clinical field required, years of experience with specialty certification can be considered in lieu of master’s degree for otherwise qualified candidates.
• Clinical licensure (RN, PharmD, RT, PT, LCSW, MLS, etc.) required
• Minimum 5 years progressive experience leading specialty specific quality/performance improvement across multiple entities (regional or system level work)
• Minimum 1 year in hospital/healthcare system quality leadership role
• Expertise in national standards and compliance frameworks (TJC, DNV, CMS Quality Reporting etc.) with fluency in data analytics tools and process improvement methodology required
• Demonstrated ability to self-organize and manage time to meet deadlines and manage competing priorities
• Strong written and verbal communication skills, able to lead meetings, present findings, and facilitate interdisciplinary collaboration
• Understanding of specific regulatory standards: CMS Conditions of Participation for LTACH and Home Health Agencies, and ambulatory accreditation standards.
• Proficient in use of organized performance improvement methodology (PDSA, lean, RCA etc.)
• Familiarity with safety event classification, failure mode effects analysis and proactive risk assessment methodologies
• Experience training teams on quality tools, regulatory compliance updates, and performance improvement techniques
• Knowledge of incident reporting system, risk mitigation strategies, and compliance protocols
• Ability to interpret clinical and operational data, develop dashboards and scorecards and use analytics tools such as excel, Tableau or Power BI
• Experience with and insight into clinical workflows specific to outpatient clinics, home health visits, and long-term acute care, including care transitions between these settings.
• Ability to align quality and performance goals with hospital-wide strategic initiatives
• Skilled in leading cross-functional initiatives, managing timelines, and delivering measurable outcomes
• Ability to guide departments through process redesign, culture shifts, and adoption of new standards
• Skilled in drafting, reviewing, and implementing policies that support regulatory compliance and operational excellence
• Ability to identify interdependencies across departments and anticipate downstream impacts of quality initiatives
• Inspire trust, model accountability, and foster a culture of continuous improvement

Nice To Haves

• Quality Certification Preferred. Examples (not exhaustive): CPQH, CPPS, CIC, HACP
• Lean six sigma – preferred

Responsibilities

• Strategic Leadership: Develop and implement quality improvement strategies that align with the health system's mission, specifically addressing the unique needs of LTACH, Ambulatory, and Home Health populations. Set measurable program goals and oversee implementation of initiatives.
• Data Driven Improvement: Analyze key performance indicators, including Home Health OASIS data, LTACH Quality Reporting Program (QRP) data, and Ambulatory quality metrics. Translate regulatory survey outcomes and benchmark data into actionable insights to drive collaborative enhancements in care delivery.
• Interdisciplinary Collaboration: Partner with clinical, operational, and administrative teams to integrate patient-centered approaches to care delivery across departments. Lead initiatives to improve care transitions and hand-offs between acute care, LTACH, and Home Health settings.
• Compliance & Standards: Ensure adherence to regulatory requirements related to patient experience and quality reporting (e.g., Home Health CAHPS, LTACH regulatory surveys). Coordinate with nursing and medicine to ensure patient experience aligns with clinical outcomes and facilitate cross-departmental initiatives to enhance communication.
• Training & Development: Lead initiatives to educate staff and leaders in quality principles, service excellence, process improvement, and communication best practices, customized for the ambulatory and home-based care environments. Cultivate a culture of accountability and empathy through targeted education and mentorship.
• Stakeholder Engagement: Serve as a liaison between health system leadership, patients, and community partners to foster transparency and trust. Utilize effective data visualization tools to provide actionable insight to LTACH, Clinic, and Home Health leadership.

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Number of Employees: 5,001-10,000 employees