VP - Quality & Performance Improvement

1000 Methodist Le Bonheur Corp; Memphis (TN); On-site; USD 100,000 - 150,000; Full time

Job summary

1000 Methodist Le Bonheur Corp in Memphis, Tennessee is seeking a VP of Quality & Performance Improvement to lead initiatives focusing on quality, patient experience, and operational efficiency.

The ideal candidate will have a Master’s Degree and at least 10 years of progressively responsible leadership experience in healthcare. Strong knowledge of quality management and performance improvement methodologies is essential.

This position demands leadership in implementing quality strategies across the organization, influencing both clinical and operational aspects.

Qualifications

• Minimum of 10 years leadership experience in healthcare quality.
• Proven success in multi-hospital quality programs and CMS reporting.
• Strong understanding of value-based care and regulatory compliance.

Responsibilities

• Lead system-wide quality and performance improvement strategies.
• Establish methodology for performance improvement across care settings.
• Oversee patient experience strategy and quality initiatives.

Skills

Quality management

Patient experience

Performance improvement methodologies

Strategic planning

Data interpretation

Communication skills

Education

Master’s Degree in Nursing, Public Health, Business Administration, Healthcare Administration or Doctorate

Tools

CMS quality programs

Healthcare analytics

HEDIS measures

Job description

Overview

In this senior leadership role, the VP of Quality & Performance Improvement leads system‑wide quality, patient experience, and performance improvement functions to drive measurable improvements in clinical outcomes, patient experience, and operational efficiency across Methodist LeBonheur Healthcare.

Responsibilities

• Develop and implement a system‑wide quality and performance improvement strategy aligned with organizational priorities.
• Establish and deploy a standardized performance improvement methodology across all care settings (acute, ambulatory, post‑acute).
• Identify and prioritize system quality improvement initiatives based on data, risk, and outcomes impact.
• Lead the system‑wide patient experience strategy, including improvement in HCAHPS and other experience metrics.
• Oversee clinical quality and process improvement initiatives, including reduction in harm, variation, and inefficiencies.
• Ensure availability of timely, accurate, and actionable quality data and analytics to support decision‑making.
• Maintain accountability for CMS programs and value‑based care performance, including Star Ratings and other regulatory metrics.
• Partner with operational, nursing, and physician leaders to align and execute quality improvement initiatives.
• Provide leadership and direction to Quality & Performance Improvement Directors across care sites.
• Drive a culture of high reliability, safety, and continuous improvement across the organization.
• Support integration of quality priorities into system governance, QAPI, and leadership structures.
• Facilitate the use of quality improvement methodologies and tools to support sustainable outcomes improvement.
• Oversee reporting and communication of quality performance to senior leadership and governance bodies.

Key Performance Indicators (KPIs)

• Implementation and adoption of a standardized system‑wide performance improvement methodology.
• Development and execution of an annual, data‑driven system quality improvement priority portfolio.
• Measurable improvement in patient experience scores across acute, ambulatory, and post‑acute settings.
• Performance improvement in CMS Star Rating and value‑based programs (VBP, HAC, Readmissions).
• Reduction in clinical harm and variation (e.g., PSI‑90, mortality, HAIs, LOS).
• Advancement of data accessibility and reporting timeliness for quality performance insights.
• Engagement of physicians, nursing, and operational leaders in quality and performance improvement initiatives.
• Standardization and reliability of improvement practices across all care sites.

Governance & Organizational Accountability

• Serve as a key executive partner to the System Quality Oversight Committee, supporting performance monitoring, prioritization of improvement initiatives, and escalation of risk and opportunity areas.
• Provide leadership alignment with QAPI (Quality Assessment and Performance Improvement) programs across all facilities and care settings.
• Partner with facility‑level Quality and QAPI councils to ensure consistency in performance improvement methodology, reporting, and accountability structures.
• Collaborate with executive and physician leadership to ensure alignment between system priorities and governance decision‑making.
• Support board and executive reporting on quality, patient experience, and value‑based performance.

Education & Qualifications

Required: Master’s Degree in Nursing, Public Health, Business Administration, Healthcare Administration, or Doctorate.

Preferred: Master’s Degree Nursing, Public Health, Business Administration, Healthcare Administration, or Doctorate.

Experience

• Minimum of ten (10) years of progressive leadership experience in healthcare quality, patient safety, regulatory, or operational improvement.
• Demonstrated success leading multi‑hospital quality programs, CMS regulatory reporting, HEDIS performance improvement, and enterprise performance improvement initiatives.
• Experience working with physicians and executive leadership in matrixed healthcare organizations.
• Strong understanding of value‑based care, population health, healthcare analytics, quality benchmarking, high reliability organizations, and regulatory compliance.

Skills and Abilities

• Demonstrated expertise in quality management, patient experience, and performance improvement methodologies.
• Advanced knowledge of CMS quality programs and healthcare regulatory requirements.
• Deep understanding of HEDIS measures and payer quality programs.
• Expertise in quality improvement methodologies and change management.
• Exceptional strategic planning and execution capabilities.
• Strong financial and operational acumen.
• Excellent communication, presentation, and relationship‑building skills.
• Ability to influence executive leaders, physicians, and interdisciplinary teams.
• Strong analytical and data‑interpretation skills.
• Demonstrated ability to lead transformational change across complex organizations.
• Excellent project management skills; coaching and mentoring skills.

Licenses and Certifications

• Certified Professional in Healthcare Quality – CPHQ (Required).
• Registered Nurse – Tennessee (Required).
• Six Sigma Yellow Belt – Authorized Six Sigma Certification Issuer (Preferred).
• Six Sigma Black Belt – Authorized Six Sigma Certification Issuer (Preferred).
• Six Sigma Green Belt – Authorized Six Sigma Certification Issuer (Preferred).
• Six Sigma Master Black Belt – Authorized Six Sigma Certification Issuer (Preferred).
• Six Sigma White Belt – Authorized Six Sigma Certification Issuer (Preferred).

Supervision Provided by this Position

• System Patient Experience leader.
• System Quality Data & Analytics leader and team.
• Care Site Quality & Performance Improvement Directors (acute, ambulatory, post‑acute).

Physical Demands

The physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion. Must have good balance and coordination.

Physical requirements include light work – exerting up to 25 lbs. of force occasionally and/or up to 10 lbs. of force frequently.

Associate is required to have close visual acuity to perform activities such as preparing and analyzing data and figures; transcribing; viewing a computer terminal; or extensive reading. The conditions to which the Associate will be subject in this position: The Associate is not substantially exposed to adverse environmental conditions; job functions are typically performed under conditions such as those found in general office or administrative work.