Director, Enterprise Quality, Data Analytics & Performance Improvement

SUMMARY:

The Director, Enterprise Quality, Data Analytics & Performance Improvement provides strategic and operational leadership for the health system's enterprise quality measurement, clinical data analytics, regulatory quality reporting, benchmarking, and performance improvement infrastructure. This leader ensures that accurate, timely, and actionable information is available to executives, boards, physicians, nursing leaders, and operational teams to improve clinical outcomes, meet external reporting requirements, and advance organizational quality priorities.

The Director leads a multidisciplinary team responsible for quality data abstraction and validation, dashboard and scorecard development, performance analysis, improvement consultation, and reporting governance. Working closely with Information Technology, Business Intelligence, Clinical Informatics, Finance, medical staff, and operational leaders, the Director translates complex data into clear insights and supports disciplined improvement across the health system.

ESSENTIAL FUNCTIONS:

ENTERPRISE QUALITY STRATEGY:
· Translate organizational strategy into an enterprise quality measurement and performance improvement agenda.
· Establish annual quality analytics and improvement priorities aligned with governance, clinical, operational, and regulatory needs.
· Advise executives and operational leaders on performance trends, risks, improvement opportunities, and resource priorities.
· Create standardized methods for defining, monitoring, escalating, and closing quality performance gaps.

QUALITY DATA ANALYTICS AND MEASUREMENT:
· Oversee collection, abstraction, validation, analysis, interpretation, and reporting of clinical quality data.
· Establish consistent measure definitions, data specifications, validation controls, and documentation standards.
· Lead benchmarking and comparative performance analysis using appropriate internal and external data sources.
· Develop analytic approaches that identify variation, emerging trends, performance gaps, and opportunities for improvement.
· Ensure analytic products are accurate, reproducible, understandable, and aligned with the intended decision and goals.

DASHBOARDS, SCORECARDS AND EXECUTIVE REPORTING:
· Lead development and maintenance of enterprise quality dashboards, scorecards, and committee reports.
· Present actionable clinical quality findings to executive leadership, boards, medical staff, and operational teams.
· Partner with Business Intelligence and Information Technology to improve data integration, visualization, automation, and reporting reliability.
· Maintain an organized reporting calendar with clear ownership, review expectations, and escalation pathways.

REGULATORY AND EXTERNAL QUALITY REPORTING:
· Oversee compliant and timely submission of required quality data to applicable regulatory, accreditation, payer, and public-reporting programs.
· Monitor changes in measure specifications and reporting requirements and coordinate operational readiness.
· Ensure source documentation, abstraction processes, validation activities, and submission records support data integrity and audit readiness.
· Collaborate with Regulatory and Accreditation leaders on quality-measure readiness and response activities.

PERFORMANCE IMPROVEMENT LEADERSHIP:
· Direct an enterprise performance improvement support model using standardized PDCA methodology and other evidence-based improvement approaches as indicated.
· Assign and prioritize improvement consultants based on strategic need, performance risk, and organizational capacity.
· Ensure improvement projects include clear aims, measures, interventions, accountability, and sustainment plans.
· Coach leaders and teams in interpreting data, identifying root causes,…