Vice President of Quality and Performance Improvement

Overview

At Catholic Health, our primary focus is the way we treat and serve our communities. We work collaboratively to provide compassionate care and utilize evidence-based practice to improve outcomes – to every patient, every time.

Position Summary:

The Vice President (VP) of Quality and Performance Improvement provides executive leadership, strategic direction, and oversight for the hospital’s quality management, regulatory compliance, accreditation, and performance improvement programs. This position ensures the delivery of effective, patient-centered, equitable, and high-quality care in accordance with applicable federal and state regulations, accreditation standards, and organizational goals.

Reporting to the Chief Medical Officer, the VP of Quality Management partners with the President, Chief Nursing Officer, medical staff, department leaders, and governing board to establish quality priorities, monitor clinical outcomes, and drive continuous improvement across the organization. The hospital’s patient safety program is led by the Risk Management leader; the VP of Quality Management works closely with that leader so that quality and patient safety efforts are coordinated and not duplicated.

Job Details

1. Quality Management and Performance Improvement

• Develop, implement, and oversee the hospital-wide quality management and performance improvement strategic plan.
• Establish measurable quality objectives, key performance indicators (KPIs), benchmarks, and performance targets aligned with organizational priorities.
• Monitor clinical outcomes, operational performance, patient experience, and quality indicators to identify opportunities for improvement.
• Lead multidisciplinary performance improvement initiatives using evidence-based methodologies, including Lean, Six Sigma, Plan-Do-Study-Act (PDSA), and root cause analysis.
• Ensure accountability for quality outcomes through performance dashboards, executive reviews, and departmental improvement plans.
• Promote the consistent use of evidence-based clinical practices and standardized care processes.
• Direct the overall functions of the Quality and Performance Improvement department, including formulating and, once approved, administering the departmental budget.
• Develop written short- and long-term departmental goals, monitor their implementation, and develop the plans needed to achieve them.
• Educate and coach department directors in process improvement methods so that their improvement projects deliver measurable results.
• Stay current with trends and innovations in performance improvement and quality management.

2. Regulatory Compliance and Accreditation

• Maintain organizational readiness for accreditation surveys, regulatory inspections, and external quality reviews.
• Oversee compliance with applicable requirements of The Joint Commission, Centers for Medicare & Medicaid Services (CMS), the New York State Department of Health (NYSDOH), and other relevant regulatory bodies.
• Coordinate survey preparation, tracer activities, document reviews, corrective action plans, and post-survey follow-up.
• Ensure timely completion of regulatory reporting, mandatory notifications, and required quality submissions.
• Partner with risk management, compliance, legal, infection prevention, nursing, medical staff, and other departments to address identified deficiencies and sustain compliance.
• Monitor regulatory changes and communicate their implications to executive leadership and clinical teams.
• Support the hospital’s Quality Assurance Committee and quality assurance program as required by New York State regulations (10 NYCRR 405.6), including reporting committee activities, findings, and recommendations to the governing body at least quarterly.
• Serve as the hospital’s liaison to IPRO and any other Medicare Quality Improvement Organizations.
• Participate in the Environment of Care Committee and support environmental rounds and Interim Life Safety Measures (ILSM) monitoring as needed for accreditation readiness.
• Provide monthly hospital-wide orientation on the hospital’s Performance Improvement Plan, regulatory agencies, EMTALA, and organ donation requirements.

3. Clinical Quality Outcomes and Data Analytics

• Oversee the collection, validation, analysis, and reporting of clinical quality and performance data.
• Monitor key indicators, including mortality, readmissions, complications, length of stay, hospital-acquired infections, and other applicable quality measures.
• Evaluate performance against national benchmarks and applicable CMS quality programs.
• Translate quality data into actionable recommendations for executive leadership, department leaders, and the governing board.
• Ensure the integrity, accuracy, and timeliness of quality reporting and performance measurement.
• Use data analytics, trend analysis, and predictive insights to identify emerging quality trends and opportunities for improvement.
• Oversee and validate the collection of Core Measure data through medical record review, including Acute Myocardial Infarction, Chest Pain, ED Measures and Throughput, Colonoscopy Screening/Surveillance, Venous Thromboembolism (VTE), Immunization, and CMS Sepsis (SEP-1).
• Validate quarterly submission of Core Measure data sets in MIDAS.
• Ensure completion of the annual Leapfrog Hospital Survey, including the Computerized Physician Order Entry (CPOE) evaluation tool conducted in a live environment with multiple disciplines.
• Partner with Infection Prevention to measure, assess, and improve infection surveillance, prevention, and control processes.

4. Medical Staff and Clinical Leadership Collaboration

• Partner with the Chief Medical Officer, Chief Nursing Officer, medical staff leadership, and clinical department chairs to improve care quality.
• Support medical staff quality oversight, peer review, clinical practice evaluation, and credentialing-related quality processes as assigned, including attending hospital-wide Peer Review meetings and trending clinical issues and mortalities.
• Facilitate multidisciplinary quality committees and clinical improvement teams.
• Promote physician and nursing engagement in quality initiatives and evidence-based practice.
• Coordinate with the Risk Management leader, who oversees the patient safety program, so that findings from safety events inform quality and performance improvement priorities.
• Integrate data from peer review, chart review, regulatory agencies, and safety event trends shared by Risk Management when working with clinical departments to improve care.
• Coordinate quarterly reporting to the hospital’s Performance Improvement Committee from Core Measures and departmental QI subcommittees, including Orthopedics, Internal Medicine/Family Practice, Endoscopy, Surgery, and Organ Donation.
• Support clinical documentation improvement and initiatives that improve care coordination, clinical outcomes, and appropriate resource utilization.

5. Board and Executive Reporting

• Present quality performance, accreditation and regulatory status, and improvement outcomes to the executive team and governing board.
• Prepare and deliver regular quality reports, dashboards, scorecards, and strategic recommendations.
• Ensure leadership has timely visibility into significant quality concerns and organizational performance gaps.
• Provide oversight of quality-related policies, procedures, governance structures, and committee effectiveness.
• Recommend strategic investments, resource allocation, and organizational priorities to improve patient outcomes.
• Represent the hospital to the CHS health system in areas of quality and performance improvement.
• Prepare and report data to the CHS Quality Monitoring Council of the Board, including system-wide and hospital-specific performance improvement metrics.
• Actively participate in the CHS Acute Care Performance Improvement Committee, setting performance goals at the system and hospital level.
• Serve as an active member of the CHS Readmissions Committee and the CHS Patient Experience Committee.

6. Leadership, Culture, and Staff Development

• Lead, mentor, and develop quality management, accreditation, and performance improvement personnel.
• Establish clear departmental goals, accountability structures, and professional development plans.
• Promote a hospital-wide culture of continuous improvement, patient-centered care, transparency, and shared accountability.
• Provide education and consultation to leaders and staff on quality improvement tools, accreditation standards, and regulatory requirements.
• Build collaborative relationships across clinical, operational, and administrative departments.

7. Patient Experience and Patient-Centered Care

• Partner with patient experience and clinical teams to improve patient satisfaction, communication, care transitions, and service recovery.
• Incorporate patient and family feedback into quality improvement priorities.
• Support initiatives that improve access, equity, care coordination, and consistency of care.
• Monitor patient experience measures and develop improvement plans for identified performance gaps.

Minimum Qualifications

• Master’s degree in Nursing, Healthcare Administration, Public Health, Quality Management, or a related field required.
• Bachelor’s degree in a relevant healthcare discipline required.
• Current, unrestricted New York State Registered Nurse (RN) license required.
• 5–10 years of healthcare quality experience, including significant responsibility for quality management, regulatory compliance, accreditation, or performance improvement.
• Minimum of 10 years of progressive hospital leadership experience.
• Demonstrated experience leading hospital-wide quality initiatives and multidisciplinary teams.
• Strong knowledge of hospital accreditation, CMS Conditions of Participation, regulatory requirements, and healthcare quality measurement.
• Proven ability to analyze complex clinical and operational data and translate findings into measurable improvements.
• Experience presenting quality performance and strategic recommendations to executive leadership and governing boards.
• Demonstrated ability to move issues to resolution.
• Ability to communicate effectively and professionally with all levels of staff, physicians, and leadership.

Preferred Qualifications and Certifications

• Certified Professional in Healthcare Quality (CPHQ).
• Certified Joint Commission Professional (CJCP).
• Lean Six Sigma certification.

Posted Salary Range

USD $280,000.00 - USD $310,000.00 /Yr.

This range serves as a good faith estimate and actual pay will encompass a number of factors, including a candidate’s qualifications, skills, competencies and experience. The salary range or rate listed does not include any bonuses/incentive, differential pay or other forms of compensation that may be applicable to this job, and it does not include the value of benefits.

At Catholic Health, we believe in a people-first approach. In addition to the estimated base pay provided, Catholic Health offers generous benefits packages, generous tuition assistance, a defined benefit pension plan, and a culture that supports professional and educational growth.

Compensation: 280000 to 310000 (USD)