System Director of Quality and Performance Improvement; Post-Acute

Overview

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).

• 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 цене 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.

• Education
  :
  Master’s degree in a 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, Pharm
  
  D, RT, PT, LCSW, MLS, etc.) required.
• Minimum Work Experience
  :
  Minimum five years progressive experience leading specialty specific quality/performance improvement across multiple entities (regional or system level work);
  Minimum one year in a 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.
• Licensures and Certifications
  :
  Licensure in a clinical field required. Quality Certification Preferred. Examples (not exhaustive): CPQH, CPPS, CIC, HACP;
  Lean Six Sigma – preferred.
• Required Skills, Knowledge, and Abilities
  :
  Demonstrated ability to self-organize and manage time to meet deadlines and manage competing priorities; strong written and verbal communication skills; 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,…