System Director, Improvement

SYSTEM DIRECTOR, PERFORMANCE IMPROVEMENT

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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.

• Bachelor’s degree in Nursing, Healthcare Administration, Public Health, Business, or related field required.
• Master’s degree in Nursing, Healthcare Administration, Quality, Business, or related field strongly preferred.

• Lean/Six Sigma Black Belt Required (Certification through American Society of Quality preferred)
• CPHQ or similar quality certification 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. Experience in the application of the Malcolm Baldrige National Quality Award Health Care criteria strongly preferred.
• 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.

• 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…