Job Information

Providence Director Quality Improvement in Laguna Beach, California



Under the direction of the Service Area Executive Director Quality, the Director Quality Improvement and Data Analytics 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.


  • Leads 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

  • Identifies and prioritizes key strategic initiatives to achieve Quality Safety and Service goals.

  • Executes and coordinates innovative strategies with leaders at the system, regional and local ministry level.

  • Demonstrates 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. Reviews 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.

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

  • Oversees the submission and validation of quarterly nurse sensitive indicators to NDNQI and other nursing databases. Utilizes 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.

  • Demonstrates service excellence and positive interpersonal relations in dealing with others.

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

  • Works 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.

  • Facilitates 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.

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

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

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

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

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

  • Collaborates 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.

  • Collaborates 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.

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

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

  • Serves as a coach and mentor to direct reports.

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


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

  • Master's Degree (preferred)

  • Upon hire: Certified Professional in Healthcare Quality (CPHQ)

  • 3 years of experience in an Acute care setting practicing within specified licensure/role

  • 5 years of progressive hospital leadership positions

  • 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

  • Requires significant discretion and knowledge of department to prioritize workload

  • Respond to multiple duties simultaneously

  • Demonstrates 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

About Providence

At Providence, our strength lies in Our Promise of “Know me, care for me, ease my way.” Working at our family of organizations means that regardless of your role, we’ll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable.

The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.

Check out our benefits page for more information about our Benefits and Rewards.

Requsition ID: 180854
Company: Providence Jobs
Job Category: Clinical Quality
Job Function: Quality/Process Improvements
Job Schedule: Full time
Job Shift: Day
Career Track: Leadership
Department: 7500 MH QUALITY ASSURE
Address: CA Mission Viejo 27700 Medical Ctr Rd
Pay Range: $65.96 - $108.29
The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.
Check out our benefits page for more information about our Benefits and Rewards.

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.