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
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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
Quality and Safety
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:
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 http://www.providenceiscalling.jobs/rewards-benefits/
We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit
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.
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.
Job Category: Non-Clinical Director/Executive
Location: California-Mission Hills
Req ID: 324047