Director, Quality & Performance Improvement

About the role

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 excellence-and 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 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 SCHEDULE: Full-time LOCATION: 759 Chestnut St- Springfield, MA Requires travel to Greenfield, Westfield, and Palmer 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 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.