System Director, Performance Improvement

Memorial Health•Springfield, IL

10h•$57 - $90

About The Position

The System Director, Performance Improvement is responsible for designing, leading, and sustaining a comprehensive, system-wide performance improvement program supported by an integrated health analytics function that advances quality, patient safety, experience, and operational efficiency across the health system. The System Director partners with executive, physician, and operational leaders to identify priority opportunities, deploy improvement methodologies, and ensure alignment with regulatory, accreditation, and strategic goals. This role provides strategic oversight of both performance improvement and health analytics, ensuring that data is transformed into meaningful, actionable intelligence that informs decision-making, drives improvement initiatives, and strengthens organizational accountability. The System Director ensures alignment between analytics, quality measurement improvement execution and maintenance of scorecards and performance monitoring systems. This position provides expertise in Lean/Six Sigma and other performance improvement methods, oversees clinical and operational improvement projects, and ensures accurate and timely reporting of key performance indicators and regulatory and externally reported measures (e.g., CMS, The Joint Commission, state programs, and public reporting), while advancing a system-wide culture of continuous improvement and data-driven performance excellence.

Requirements

Bachelor’s degree in Nursing, Healthcare Administration, Public Health, Business, or related field required.
Lean/Six Sigma Black Belt Required (Certification through American Society of Quality preferred)
Minimum 5–7 years of progressive experience in healthcare quality, performance improvement, or related field, with at least 3 years in a leadership role (manager or above).
Demonstrated experience leading complex, multi-disciplinary improvement projects in a hospital or integrated health system, including successful outcome and process measure improvement.
Experience with regulatory/accreditation standards (CMS, The Joint Commission, state health departments) and external quality reporting programs.
Experience using data and analytics tools (e.g., dashboards, statistical process control, basic statistical analysis) to support improvement and decision-making.
Demonstrated success implementing PI methodologies (e.g., Lean/Six Sigma, FOCUS-PDCA, PDSA) and achieving measurable improvements in outcomes, efficiency, or patient experience.
Working knowledge of accreditation standards (Joint Commission, CARF, etc.) required.
Demonstrated ability to perform complex data analysis, draw appropriate conclusions, and convey recommendations to all levels of the organization through written reports and group presentations.
Demonstrated ability to work in a team environment and to promote cooperation, collaboration, and high performance within and across disciplines.
Excellent written and verbal communication skills, with ability to communicate effectively with all levels of the organization.
Ability to work independently and to manage multiple tasks in a fast-paced environment.
Strong, analytical, planning, problem-solving and organizational skills.
Strong sense of ownership and high level of accountability.
Proficient in word processing, spreadsheet, project, and presentation computer application software. Experience with Microsoft Office products (Word, Excel, Project, and Power Point) is strongly preferred

Nice To Haves

Master’s degree in Nursing, Healthcare Administration, Quality, Business, or related field strongly preferred.
CPHQ or similar quality certification preferred.
Experience in the application of the Malcolm Baldrige National Quality Award Health Care criteria strongly preferred.

Responsibilities

Assists and advises organizational leaders, physicians, and staff with the identification and improvement of operational and clinical processes which will positively impact safety, quality, and clinical effectiveness.
Provides management oversight to the performance improvement function throughout the system.
Provides process management, project support and assistance in facilitation of organizational performance improvement and safety initiatives.
Provides internal consulting services to managers and physicians regarding best demonstrated practices, and industry benchmarks.
Coordinate efforts that will further Memorial’s ability to meet or exceed, on a continual basis, all accreditation standards (e.g. Joint Commission) and Malcolm Baldrige National Quality Award Health Care criteria.
Assist organizational leaders with the prioritization of opportunities to achieve performance excellence through the reduction or elimination of process or outcome variation.
Participate in the development of annual quality improvement goals and action plans consistent with MHS’s strategic plan and monitor the status of goal achievement throughout the year, making changes as necessary.
Seeks opportunities to utilize and coach individuals in the use of quality and safety tools and techniques.
Provides interpretation of MHS and departmental policies, objectives and operational procedures, and represents these policies, objectives and procedures in a positive professional manner to all supervised staff.
Supports leadership in the maintenance of effective budgetary controls on matters of staffing, expenses, and capital equipment expenditures; ensures that all departmental initiatives are cost effective and monitors the effectiveness of all departmental programs and services.
Encourages professional and personal growth of staff through the participation and involvement of in-services and educational programs and keeping current with reading industry-related literature.
Coordinates and facilitates staff, physician, and partner education and mentorship across the system in Lean Six Sigma and related process improvement techniques.
Provides assistance to partners in the performance improvement function as necessary, including the Midwest Healthcare Quality Alliance and the Quality Alliance Patient Safety Organization.
Performs other related work as required or requested.
The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job. Incumbents may be requested to perform tasks other than those specifically presented in this description.