Director, Improvement

Overview

St. Mary's General Hospital, located in Passaic, NJ, is a community-based tertiary medical center focused on providing quality, compassionate care. It is an acute care hospital providing a broad range of services including cardiovascular services as well as a comprehensive program for cancer care. The hospital is also a center of excellence for maternal‑child health and outpatient behavioral health services. It is the only hospital in Passaic and with over 550 physicians and 1,000 employees, and is one of the largest employers in the county.

Every member of the St. Mary's General team is committed to providing respectful, personalized, high‑quality care. St. Mary's General Hospital is a member of Prime Healthcare, which has been lauded as a "Top 15 Healthcare System" by Truven Health Analytics. For information, visit

The Performance Improvement Director develops, manages and integrates a comprehensive Performance Improvement (PI) Program to achieve unprecedented results in quality, efficiency, safety, satisfaction and value with transparency.

The Managerial oversight responsibility of the Performance Improvement Program is to develop and share best practices for improving performance in quality, safety, perception of care, value and efficiency; to develop/maintain scorecards for all Service Lines with defining expected outcomes & benchmarks based on Quality, Safety, Satisfaction and Value; to complete Clinical Assessment, Diagnosis and Treatment for the Service Lines. Responsible for coordinating and managing hospital wide performance improvement activities including continued survey readiness.

Responsible for oversight of on‑going publicly reported quality initiatives undertaken by the organization, like Core Measures, Patient Satisfaction, etc. Work collaboratively with Administration and Leadership. Ensures execution and communication of Performance Improvement and Patient Safety activities occurs from the department level to Board of Trustees.

The scope of activities in managing the PI Program, includes creating collaborative customer relationships; planning appropriate group processes; creating & sustaining a participatory environment; guiding the group to appropriate & useful outcomes; building and maintaining professional knowledge; employing evidence‑based practice; integrating best research with expertise & patient values for optimal care; working in interdisciplinary teams; application of performance improvement methodologies to minimize waste, decrease errors, increase efficiency and ultimately improve care and appropriate utilization of informatics to communicate, manage knowledge with clinical expertise and patient values for optimal care.

Team facilitation and experience with hospital accreditation standards and survey process preferred. Knowledge of local regulatory standards & OSHA regulations a plus.

Education and Work Experience

• Bachelors Degree in a healthcare related field required, plus 4 years of work experience in healthcare related field. 1 year of work experience in performance improvement.
• Masters Degree with 3 years of work experience, including 1 year of work experience in performance improvement preferred.
• Good computer skills.
• Experience in reviewing charts for quality care issues. Detail oriented organizational skills. Must be able to handle multiple cases, directions and follow-through.
• Good communication skills both verbally and written. Experience with Medical Staff communication.
• Coordination of internal departments and external entities to ensure compliance with company policies, and state/federal regulatory and accreditation standards.
• Certification in Professional in Healthcare Quality (CPHQ) or Healthcare Accreditation highly desirable.

St. Mary's General Hospital offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary…