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

Performance Improvement Manager

At Boston Medical Center - South, we are committed to improving the health of our communities by delivering exceptional, personalized health care with dignity, compassion and respect. Our continued focus on the patient experience informs our caregivers on how to provide care that is respectful of and responsive to individual patient and family preferences, needs and values. If you are seeking a fast-paced, challenging position in an organization committed to achieving and maintaining a standard of excellence in all we do, our organization may be a good fit for you.

Schedule : 40 Hours, Days, Full Time, Benefit-Eligible

Summary : The performance improvement manager will support the implementation and monitoring of programs and activities designed to ensure that Boston Medical Center South incorporates methods to improve the safe administration of care into all clinical processes, while developing a culture that perceives safety to be of paramount importance. The Performance Improvement Manager will also be expected to collaborate and provide guidance to hospital staff daily to identify and remove barriers to ensure an error-free clinical and non-clinical setting consistent with defined regulating and accreditation standards (Joint Commission, Medicare Conditions of Participation, Departments of Public Health, Mental Health, etc). The Performance Improvement Manager will serve as the hospital's lead to ensure a continuous state of readiness and meeting all Joint Commission, CMS and DPH standards by standardizing processes for evaluation of compliance of standards, identifying opportunities for improvement, implementing changes to hospital operations to meet expected regulatory readiness, measuring effectiveness of interventions with standardized tracer and audit activities. This job reports to the Sr. Director of Quality and Behavioral Health Services.

Responsibilities :

• 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.
• Identify and implement 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.

Requirements :

Equal Opportunity Employer / Disabled / Veterans

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