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Providence Health & Services Director, Quality Improvement Data Analytics in Mission Hills, California


Providence is calling a Director, Quality Improvement Data Analytics (Full-Time, Day Shift) to Providence Holy Cross Medical Center in Mission Hills, CA

Please upload a current resume reflecting all relevant experience.

Apply today! Applicants that meet qualifications will receive a text with additional questions from our MODERN HIRE system.

We are seeking a Director, Quality Improvement Data Analytics who will be responsible for planning, designing, directing, and executing performance improvement work in alignment with the Value Triple Aim (Quality, Service and Cost Excellence). The Director will partner with Ministry physician, clinical and operational leaders to develop the infrastructure, reporting mechanisms and strategies to facilitate Performance Improvement and achievement of Providence system, regional and ministry-specific goals and strategic initiatives. The Director will ensure the proper preparation and coordination of resources needed to achieve regulatory compliance related to the CMS COP Quality Assessment and Performance Improvement (QAPI) Plan and QAPI Annual Evaluation, and The Joint Commission standards, Co-chaired Quality Committee related to performance improvement, to include the collection, analyses, reporting and on-going monitoring of quality and safety data needed to meet accreditation requirements.

The Director Quality Improvement and Data Analytics develops, monitors and effectively regulates departmental budgets. Serves as a catalyst and mentor for motivating productivity, innovation, improvement, high employee morale and commitment to the organization.

The Director Quality Improvement and Data Analytics may act on behalf of the service area executive director at ministry, regional, and system-level meetings.

In this position you will:

  • Lead execution of ministry-specific data analytics and performance improvement infrastructure

  • Facilitates the local adoption of the Performance Improvement process throughout the Ministry acting as a coach and mentor for Ministry, departmental, and unit improvement teams

  • Identify and prioritize key strategic initiatives to achieve Quality Safety and Service goals

  • Execute and coordinate innovative strategies with leaders at the system, regional and local ministry level

  • Demonstrate sustainable progress on improvement priorities, and monitors & reports ministry progress to executive leadership, Medical staff, and Governing body

  • Act as primary resource to Clinical Institute/Service Line leaders to provide and/or interpret data for decision making including VOA cost data, clinical outcomes, LOS, payment data from payors, and physician outcomes

  • Review mortalities, and other outcomes as needed and coordinates action plans with ministry leadership (CMO, CNO, department leadership, & Service Area Executive DQ

  • In collaboration with regional data analytics, ensures service line clinical institute leaders are knowledgeable and have access to actionable and timely data and oversight internal monthly reporting of key executive clinical institute metrics via quality report.

  • Analyzing, trending, monitoring, and presenting data to core leaders, service line leaders, physicians, etc. and collaborating to drive improvement through developed action plans

  • Oversee the submission of outcomes data for different payor designations and programs, e.g., Blue Distinction, Anthem, etc.

  • Oversee the submission and validation of quarterly nurse sensitive indicators to NDNQI and other nursing databases

  • Utilize the clinical, operational and/or cost outcome reports, trends, and coordinates with the magnet coordinator to communicate progress to nursing leadership

  • In collaboration with Magnet coordinator routinely identifies appropriate data for Magnet Sources of Evidence

  • In collaboration with care experience leader evaluates impact of patient experience to CMS, US News, Healthgrades national programs

  • Provide oversight to development of Performance Improvement plan to improve these national rankings performance

  • Oversight of data analytics in collaboration with ministry specific leaders for specialty certification designation

  • Coordinate efforts with regional data team to ensure all externally reported data are accurate and comprehensive at the time of reporting, including the review fallouts cases, and coordinates action plans as needed

  • Strategic oversight of organizational performance that is externally reported, ensuring escalation, leadership awareness and performance improvement strategies are implemented. (e.g., insurance payor quality metrics, CMS, national quality registries

  • Act as hospital’s QNET administrator – upload required outcomes, i.e., CDAC validation outcomes

  • Oversight of download measure outcomes, PEPPER reports, Preview reports etc., and ensure process for review and dissemination to Ministry leaders, as appropriate

  • Demonstrate service excellence and positive interpersonal relations in dealing with others

  • Assure the standardization and consistency of quality performance improvement activities throughout the organization

  • Work collaboratively with risk management, patient safety, regulatory, and regional/service area leadership Service Area Quality to develop standardized processes and share “learnings” throughout the service area, region, and Providence system

  • Facilitate the establishment of organization monitoring and evaluation of PI/patient safety activities using identified quality indicators, and maintains confidentiality of all information related to patients, medical staff, employees, and as appropriate, other information

  • Assist in the orientation and ongoing education and mentoring of leaders and caregivers in the quality performance improvement process in collaboration with regional PI team

  • Supervise the collection, assessment and presentation of information to facilitate the ongoing measurement of processes and outcomes

  • Assist, as necessary, in the collection of data for key quality performance indicators

  • Develop systems and processes to assure the reliability, accuracy and confidentiality of information used in the department functions

  • Work collaboratively with Risk Management, Patient Safety, Regulatory, and Infection Prevention on the integration of risk, patient safety, quality improvement and regulatory compliance

  • Collaborate with regional Executive Director of Quality to support Medical Staff leadership in the development and implementation of systems and processes to identify practice variations and opportunities for improvements in patient care processes and/or outcomes for the organization

  • Collaborate with regional Executive Director of Quality and the use of regional PI staff’s use of the performance improvement methodology to provide PI support to the organization

  • Work collaboratively with the Ministry Regulatory Program, physician, operational and clinical leaders to ensure ongoing survey readiness

  • Provide comprehensive reports of quality performance improvement activities to PI teams, applicable Medical Staff committees, and organization board(s).Community Ministry Board

  • Serve as a coach and mentor to direct reports

  • Maintain professional growth and development through participation in seminars, educational programs, workshops, and professional affiliations


Required qualifications for this position includes:

  • Bachelor's Degree in Health-related field -or- equivalent education/experience

  • Three (3) years of acute care setting practicing within specified licensure/role

  • Demonstrate a working knowledge of national healthcare trends in quality improvement and management

  • Working knowledge of The Joint Commission standards and/or regulatory agency requirements regarding PI/Quality

  • Work efficiently and effectively in a matrix structured environment

  • Understand the needs and preferences of customers served

  • Must possess strong presentation and interpersonal skills that display a presence of leadership in a wide range of settings

  • Skills:

  • Quality and Safety

  • Driving improvement

  • Risk Assessment

  • Conflict Resolution

  • Staff Development

  • Interpersonal Communication

  • Must be organized, detail oriented and like to work with statistics and evaluation of methodologies

  • Efficiently problem solve, while dealing with a diverse set of systems and individuals

  • Developing and motivating staff to their highest potential, using strong leadership skills and interpersonal communication skills

  • Sgnificant discretion and knowledge of department to prioritize work load

  • Respond to multiple duties simultaneously

  • Demonstrate expertise in healthcare data analytics and performance improvement methodology, with the ability to take complex data sets, effectively data mine, and through analysis identify pertinent insights an interpretation providing actionable insights to drive quality improvement activities

Preferred qualifications for this position includes:

  • Master's Degree

  • Current California Registered Nurse License, or equivalent or higher level licensure or equivalent experience and expertise in quality data analytics

  • Certified Professional in Healthcare Quality CPHQ

  • Five (5) years of Progressive hospital leadership positions

About the hospital you will serve.

Nationally recognized for clinical excellence and trauma care, Providence Holy Cross Medical Center is a 377-bed, level II trauma center in Mission Hills, California. We are the only Magnet®Designated Hospital in the San Fernando Valley. Providence Holy Cross also has been recognized this year by the Los Angeles Business Journal as one of the best places to work in Los Angeles. As our reputation for excellence grows, so does our facility. We have recently expanded our medical center with the addition of a new 138-bed patient care wing. This expansion has made Providence Holy Cross Medical Center one of the largest hospitals serving the San Fernando and Santa Clarita valleys.

We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit

We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit

Our Mission

As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.

About Us

Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.

Schedule: Full-time

Shift: Day

Job Category: Non-Clinical Director/Executive

Location: California-Mission Hills

Req ID: 324047