Director, Quality & Performance Improvement

Baystate Health a nationally recognized leader in healthcare quality and safety is seeking a strategic and analytically driven Director of Quality & Performance Improvement to shape and lead system-wide quality reporting performance measurement and improvement initiatives in Springfield MA.

This is a high-impact leadership role for a candidate who thrives at the intersection of data clinical quality and operational excellenceand who is passionate about turning insights into measurable improvements in patient care.

RESPONSIBILITIES: Reporting to the Vice President Quality & Safety The Director of Quality & Performance Improvement serves as a system leader responsible for building and sustaining a high-performing quality close partnership with Patient Safety leadership you will align quality performance safety priorities and regulatory requirements to drive meaningful sustainable outcomes across the organization.

Drive System-Wide Quality Strategy & Analytics

• Lead the design and execution of system-wide quality reporting including internal and external metrics (CMS Joint Commission DPH Leapfrog payer programs)
• Ensure the integrity accuracy and timeliness of clinical quality data and submissions
• Oversee dashboards scorecards and performance tools that promote transparency and informed decision-making
• Translate complex data into actionable insights to identify trends variation and improvement opportunities
• Partner with informatics and analytics teams to strengthen data infrastructure and reporting capabilities

Lead Performance Improvement at Scale

• Direct system-wide performance improvement initiatives aligned with strategic and regulatory priorities
• Standardize and deploy evidence-based methodologies (PDSA FMEA Lean principles change management)
• Facilitate interdisciplinary efforts to address high-risk or underperforming areas and ensure measurable sustained results
• Establish accountability through milestone tracking performance monitoring and risk escalation

Advance Systems Thinking & Reduce Variation

• Identify unwarranted variation through benchmarking and data analysis
• Collaborate with operational leaders to redesign workflows processes and care models
• Promote scalable system-level solutions that address root causes and improve reliability and outcomes

Ensure Regulatory Alignment & Survey Readiness

• Align quality performance metrics with CMS Joint Commission DPH and payer program requirements
• Partner with Patient Safety leadership to integrate performance data with safety events RCA findings and risk mitigation strategies
• Support survey readiness by ensuring data documentation and outcomes demonstrate sustained compliance
• Interpret regulatory requirements and translate them into actionable performance strategies

Champion High Reliability & Culture of Accountability

• Advance High Reliability Organization (HRO) principles through data transparency and standard work
• Reinforce a Just Culture by using data to drive improvementnot punitive action
• Empower leaders to use performance data to engage teams and sustain results
• Foster a culture of continuous learning by connecting data outcomes and improvement efforts

Oversee Patient Safety Event Reporting System

• Provide administrative and strategic oversight of the Safety Reporting System (SRS)
• Ensure optimal system configuration data integrity and effective event analysis
• Leverage benchmarking to identify trends and inform improvement priorities
• Integrate safety event data with quality patient experience and nursing-sensitive outcomes

Build & Develop High-Performing Teams

• Lead and develop a team of analysts quality specialists and performance improvement professionals
• Strengthen organizational capability in data literacy and improvement science
• Establish competencies in quality measurement analytics and performance improvement methodologies
• Align workforce planning with evolving organizational priorities

SCHEDULE:

• Full-time

LOCATION:

• 759 Chestnut St- Springfield MA
• Requires travel to Greenfield Westfield and Palmer

QUALIFICATIONS:

• Masters Degree (MPH MHA MBA or related field) required
• Clinical or healthcare-related degree preferred
• CPHQ or equivalent certification in healthcare quality/performance improvement
• 5 years of progressive leadership experience in healthcare quality analytics or performance improvement
• Deep knowledge of CMS Joint Commission and payer-based quality programs
• Proven success leading large-scale data-driven improvement initiatives
• Strong analytical strategic thinking and change management skills
• Ability to influence and collaborate across clinical and operational leadership

Education:

Certifications:

Compensation

Note: The compensation range(s) in the table below represent the base salaries for all positions at a given grade across the health system. Typically a new hire can expect a starting salary somewhere in the lower part of the range. Actual salaries may vary by position and will be determined based on the candidates relevant experience. No employee will be paid below the minimum of the range. Pay ranges are listed as hourly for non-exempt employees and based on assumed full time commitment for exempt employees.

Minimum - Midpoint - Maximum

Equal Employment Opportunity Employer