Vice President of Quality and Performance Improvement

Catholic Health•West Islip, NY

About The Position

The Vice President of Quality and Performance Improvement provides executive leadership, strategic direction, and oversight for the hospital’s quality management, regulatory compliance, accreditation, and performance improvement programs. The role ensures effective, patient-centered, equitable, high-quality care consistent with federal and state regulations, accreditation standards, and organizational goals. Reporting to the Chief Medical Officer, the VP partners with the President, Chief Nursing Officer, medical staff, department leaders, and governing board to set quality priorities, monitor clinical outcomes, and drive continuous improvement. The VP coordinates closely with the Risk Management leader, who leads the patient safety program, to align quality and safety work. The VP develops and oversees the hospital-wide quality and performance improvement plan; establishes objectives, measures, benchmarks, and targets; monitors clinical outcomes, operational performance, patient experience, and quality indicators; and leads multidisciplinary improvement initiatives. The role directs the Quality and Performance Improvement department, including its budget after approval, departmental goals, staff development, and improvement coaching. The position oversees accreditation readiness, regulatory compliance, survey preparation, corrective action plans, required reporting, and regulatory monitoring. It also oversees quality data collection, validation, analysis, and reporting; monitors clinical outcomes and performance against national benchmarks; and translates findings into recommendations for executive leadership and the governing board. Responsibilities include oversight of specified Core Measure data, quarterly MIDAS submissions, the annual Leapfrog Hospital Survey, and collaboration with Infection Prevention. The VP works with medical and clinical leaders on quality oversight, peer review, clinical improvement, documentation, and appropriate resource utilization; reports quality performance and regulatory status to executive and governing bodies; represents the hospital in CHS quality activities; and promotes a culture of continuous improvement, transparency, patient-centered care, and shared accountability. The role also partners with patient experience and clinical teams to improve satisfaction, communication, care transitions, service recovery, access, equity, and care coordination.

Requirements

Master’s degree in Nursing, Healthcare Administration, Public Health, Quality Management, or a related field.
Bachelor’s degree in a relevant healthcare discipline.
Current, unrestricted New York State Registered Nurse (RN) license.
5–10 years of healthcare quality experience, including significant responsibility for quality management, regulatory compliance, accreditation, or performance improvement.
Minimum of 10 years of progressive hospital leadership experience.
Demonstrated experience leading hospital-wide quality initiatives and multidisciplinary teams.
Strong knowledge of hospital accreditation, CMS Conditions of Participation, regulatory requirements, and healthcare quality measurement.
Proven ability to analyze complex clinical and operational data and translate findings into measurable improvements.
Experience presenting quality performance and strategic recommendations to executive leadership and governing boards.
Demonstrated ability to move issues to resolution.
Ability to communicate effectively and professionally with all levels of staff, physicians, and leadership.

Nice To Haves

Certified Professional in Healthcare Quality (CPHQ).
Certified Joint Commission Professional (CJCP).
Lean Six Sigma certification.

Responsibilities

Develop, implement, and oversee the hospital-wide quality management and performance improvement strategic plan.
Establish measurable quality objectives, KPIs, benchmarks, and performance targets aligned with organizational priorities.
Monitor clinical outcomes, operational performance, patient experience, and quality indicators to identify improvement opportunities.
Lead multidisciplinary performance improvement initiatives using evidence-based methods, including Lean, Six Sigma, PDSA, and root cause analysis.
Promote accountability for quality outcomes through dashboards, executive reviews, and departmental improvement plans.
Promote evidence-based clinical practices and standardized care processes.
Direct the Quality and Performance Improvement department, including formulating and administering its budget once approved.
Develop and monitor short- and long-term departmental goals and plans; coach department directors in process improvement methods.
Maintain readiness for accreditation surveys, regulatory inspections, and external quality reviews.
Oversee compliance with requirements of The Joint Commission, CMS, NYSDOH, and other relevant regulatory bodies.
Coordinate survey preparation, tracer activities, document reviews, corrective action plans, and post-survey follow-up.
Ensure timely regulatory reporting, mandatory notifications, and required quality submissions.
Collaborate with relevant departments to address deficiencies and sustain compliance; monitor regulatory changes and communicate implications.
Support the Quality Assurance Committee and program, including quarterly reporting of activities, findings, and recommendations to the governing body as required.
Serve as the hospital’s liaison to IPRO and other Medicare Quality Improvement Organizations.
Participate in the Environment of Care Committee and support environmental rounds and ILSM monitoring as needed.
Provide monthly hospital-wide orientation on the Performance Improvement Plan, regulatory agencies, EMTALA, and organ donation requirements.
Oversee collection, validation, analysis, and reporting of clinical quality and performance data; ensure data integrity, accuracy, and timeliness.
Monitor quality indicators including mortality, readmissions, complications, length of stay, hospital-acquired infections, and applicable quality measures.
Evaluate performance against national benchmarks and applicable CMS quality programs, and translate data into actionable recommendations.
Use analytics, trend analysis, and predictive insights to identify emerging trends and improvement opportunities.
Oversee and validate Core Measure data collection through medical record review, including the measures listed in the posting; validate quarterly Core Measure data-set submission in MIDAS.
Ensure completion of the annual Leapfrog Hospital Survey, including the live-environment CPOE evaluation with multiple disciplines.
Partner with Infection Prevention to measure, assess, and improve infection surveillance, prevention, and control processes.
Partner with medical and nursing executives, medical staff leaders, and clinical department chairs to improve care quality.
Support medical staff quality oversight, peer review, clinical practice evaluation, and assigned credentialing-related quality processes; attend hospital-wide Peer Review meetings and trend clinical issues and mortalities.
Facilitate multidisciplinary quality committees and clinical improvement teams; promote physician and nursing engagement in quality initiatives and evidence-based practice.
Coordinate with Risk Management so safety-event findings inform quality priorities, and integrate relevant peer review, chart review, regulatory, and safety-event data into improvement work.
Coordinate quarterly Performance Improvement Committee reporting from Core Measures and departmental QI subcommittees.
Support clinical documentation improvement and initiatives to improve care coordination, clinical outcomes, and appropriate resource utilization.
Present quality performance, accreditation and regulatory status, and improvement outcomes to executive leadership and the governing board.
Prepare quality reports, dashboards, scorecards, and strategic recommendations; ensure timely visibility into significant concerns and performance gaps.
Oversee quality-related policies, procedures, governance structures, and committee effectiveness; recommend strategic investments, resources, and organizational priorities.
Represent the hospital to the CHS health system on quality and performance improvement matters; prepare and report data to the CHS Quality Monitoring Council of the Board.
Participate in the CHS Acute Care Performance Improvement Committee and help set system- and hospital-level performance goals; serve on the CHS Readmissions and Patient Experience committees.
Lead, mentor, and develop quality management, accreditation, and performance improvement personnel; establish goals, accountability structures, and professional development plans.
Promote a hospital-wide culture of continuous improvement, patient-centered care, transparency, and shared accountability; educate and consult with leaders and staff.
Build collaborative relationships across clinical, operational, and administrative departments.
Partner with patient experience and clinical teams to improve patient satisfaction, communication, care transitions, and service recovery.
Incorporate patient and family feedback into quality priorities; support access, equity, care coordination, and consistency of care initiatives.
Monitor patient experience measures and develop improvement plans for identified performance gaps.