Healthcare Quality & Safety Performance Improvement Manager (40 Hours, Days)

• Coordinate hospital-wide performance improvement initiatives by developing, implementing, and monitoring programs aimed at enhancing clinical safety and regulatory compliance. Utilize data analysis, process standardization, and collaboration with clinical and administrative leaders to drive continuous improvement. 

• Manage regulatory readiness programs to ensure compliance with standards set by The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), Department of Public Health (DPH), and other accrediting bodies. This includes coordinating survey activities, preparing required documentation, conducting tracer rounds and audits, and developing corrective action plans. 

• Collect, analyze, and report quality, patient safety, and equity-related data for internal use and submission to external agencies such as MassHealth Hospital Health Equity Incentive Program. Ensure data accuracy, timeliness, and relevance to inform decision-making and compliance. 

• Serve as the liaison for quality and safety committees and interdisciplinary teams, facilitating communication and collaboration across departments to promote a culture of safety and regulatory readiness. 

• Identifies and implements educational programs and resources for hospital staff and leadership to ensure understanding of regulatory standards and performance expectations. Foster a team-based approach to maintain ongoing compliance and readiness. 

• Operationalize and oversee specialized programs, including the Metabolic and Bariatric Surgery program, ensuring these services meet all clinical quality and regulatory requirements. 

• Support clinical leadership in patient safety initiatives by analyzing trends in adverse events and quality measures, recommending and implementing interventions to reduce preventable harm and improve outcomes aligned with Joint Commission priorities. 

• Maintain continuous awareness of regulatory changes and updates, translating new requirements into actionable plans and hospital-wide process improvements to ensure sustained compliance. 

JOB REQUIREMENTS

• Bachelor of Science in health care related field and 5 years in Health Care Quality or Performance Improvement role; or equivalent combination of education and experience are required.
• Master of Science in health care field preferred.
• Certified Lean Six Sigma Green Belt ​preferred.
• Highly motivational communication skills accompanied by the ability to analyze and present data to influence behavior, stimulate innovation, promote best practices, and drive organizational change.  
• Strong presentation skills.  
• Strong computer skills including Microsoft Office platform — Word, Access, Excel, E-mail, Web/Internet.
• Demonstrated ability to create and sustain momentum through relationship building, and collaborative management. 
• Ability to learn and effectively use computer software, such as electronic health records and data.