Director, Quality & Performance Improvement

100 Baystate Medical Center; United States; On-site; USD 158,000 - 215,000; Full time

Job summary

Baystate Health, based in Springfield, MA, seeks a Director of Quality & Performance Improvement to lead system-wide quality strategy and analytics. In collaboration with Patient Safety, you will align quality, safety priorities, and regulatory requirements to drive meaningful, sustainable outcomes across the organization.

You will oversee performance improvement at scale, standardize evidence-based methodologies, and empower leaders to use performance data to sustain results, fostering a

Qualifications

• 5+ years of progressive leadership experience in healthcare quality, analytics, or performance improvement.
• Deep knowledge of CMS, Joint Commission, and payer programs.
• Proven success leading large-scale, data-driven improvement initiatives.
• Strong ability to influence across clinical and operational leadership.

Responsibilities

• Lead system-wide quality reporting including CMS and regulatory metrics.
• Ensure the integrity, accuracy, and timeliness of quality data submissions.
• Oversee dashboards, scorecards, and performance tools for transparency and decision-making.
• Translate complex data into actionable insights to identify trends and improvement opportunities.
• Promote high reliability and a culture of accountability through data-driven action.

Skills

Analytical thinking

Strategic thinking

Change management

Leadership

Education

Masters Degree in health-related field

Clinical/healthcare-related degree preferred

Job description

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 infrastructure. In 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 improvement - not 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.

QUALIFICATIONS:

Master's 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: Masters Degree (Required) Certifications: Healthcare Quality or Performance Improvement - CPHQ 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 candidate's 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 $158,371.00 - $182,041.00 - $215,342.00

SCHEDULE:

Full-time

LOCATION:

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

Equal Employment Opportunity Employer

Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.

About Baystate Health

Baystate Health (BH) is one of New England’s leading and largest integrated health care organizations, serving a population of nearly one million people throughout western New England. With roots dating back to the founding of Springfield City Hospital in 1873, Baystate Health has been providing high-quality and compassionate health care in western Massachusetts for more than 145 years. With more than 12,000 employees, a medical staff of nearly 3,100 physicians, and a net patient service revenue of more than $1.4 billion, the ever-growing health system includes five Massachusetts hospitals and the Baystate Mary Lane Outpatient Center in Ware: Baystate Medical Center in Springfield Baystate Children’s Hospital (located at Baystate Medical Center) Baystate Franklin Medical Center in Greenfield Baystate Wing Hospital in Palmer Baystate Noble Hospital in Westfield