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Providence Health & Services Sr. Manager, Performance Improvement in Mission Hills, California


Providence is calling a Senior Manager, Performance Improvement (Full-Time/Day Shift) to Providence Holy Cross Medical Center in Mission Hills, CA.

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We are seeking a Senior Manager, Performance Improvement who will Under the direction of the service area executive director quality the senior manager quality improvement and data analytics this position will be responsible for planning, designing and directing performance improvement work in alignment with the Value Triple Aim (Quality, Service and Cost Excellence). The Senior manager will coordinate and develop the infrastructure and strategies to facilitate the implementation of Performance Improvement and achievement of PSJH goals, including integration of system-wide & ministry strategic initiatives, and performance improvement strategies, projects, and activities with system, region, and local ministry priorities in coordination with quality and performance improvement leaders. They ensures the proper preparation and coordination efforts to achieve regulatory compliance with The Joint Commission and other regulatory agencies for Quality Indicators. The senior manager quality improvement and data analytics develops, monitors and effectively regulates departmental budgets. Serves as a catalyst and mentor for motivating productivity, innovation, high employee morale and commitment to the organization.

In this position you will:

  • Oversight of Analysis & Tracking

  • Perform data analysis and develops/drives & execute innovative strategies to achieve Quality, Service, & Strategic goals. Monitor & report ministry progress to executive leadership in PI & Strategic Implementation. Develop, coordinate and implement sustainability progress on improvement activities in collaboration with improving performance leaders at the system, regional and local ministry level.

  • Act as primary resource to Service Line leaders to provide data for decision making including VOA cost data, clinical outcomes, LOS, payment data from payors, physician outcomes.

  • Provide outcomes for different payor designations, i.e., Blue Distinction, Anthem Create monthly quality report for presentation by Executive Lead by pulling most current data and working with leaders for their input

  • Develop trend charts puling most appropriate data for all Magnet outcomes related to clinical stories

  • In collaboration with care experience leader, Provide Patient Experience outcomes from Press Ganey related to overall outcomes for hospital, units/departments, physicians

  • Support Stroke service line support for Comprehensive Stroke certification with support of RedCap tool for all Code Stroke data and data flow into Quintiles and Joint Commission

  • Responsible for external data reporting: Clean all errors in data transmission file prior to upload to Premier. Enter Hip & Knee abstractions and CSTK Stroke abstractions in Joint Commission website.

  • Review all CMS and JC data abstractions with Q Centrix team, including stroke, hip & knee, and all other required quality metrics. Review for fall outs and for accuracy.

  • Review all CMS re-admissions with service line leads and coordinate action plans with regional service area executive director of quality.

  • Review mortalities >3 ROM score coordinate action plans with regional service area executive director of quality.

  • Build monthly and ad hoc reports in WEBI and AMALGA to review trends for exec team and unit leaders.

  • Act as hospital’s QNET administrator – upload required outcomes, i.e., CDAC validation outcomes. Download measure outcomes, PEPPER reports, etc.

  • Maintain confidentiality of all information related to patients, medical staff, employees, and as appropriate, other information.

  • Demonstrate service excellence and positive interpersonal relations in dealing with others.

  • Facilitate the PI process throughout the organization acting as a facilitator and mentor for department improvement teams.

  • Assure the standardization and consistency of quality performance improvement activities throughout the organization.

  • Work collaboratively with regional service area Executive Director Quality PI/Patient Safety/Accreditation leaders to develop standardized processes and share “learnings” throughout the community, region, and Providence Health and Services System.

  • Facilitate the establishment of organization monitoring and evaluation of PI/patient safety activities using identified quality indicators.

  • Assist in the orientation and ongoing education of employees in the quality performance improvement process in collaboration with regional PI team.

  • Provide staff support for identified organization quality committees/councils and service lines.

  • Interpret raw data and performs and/or facilitates comparative analysis of clinical data.

  • Assist in the development, revision and evaluation of quality improvement plans. Actively work with physician leadership, directors and managers in the development and implementation of quality performance improvement plans.

  • Keep regional executive director quality , physicians and management apprised of issues requiring actions and communicates regularly about progress/trends toward key quality indicators.

  • Supervise the collection, assessment and presentation of information to facilitate the ongoing measurement of processes and outcomes.

  • Assist, as necessary, in the collection of data for the defined indicators.

  • Develop systems and processes to assure the reliability, accuracy and confidentiality of information used in the department functions.

  • Work collaboratively with Risk Management, Patient Safety, and Regulatory on the integration of risk, patient safety, quality improvement and regulatory compliance.

  • Collaborate with regional executive director of quality to support Medical Staff leadership in the development and implementation of systems and processes to identify practice variations and opportunities for improvements in patient care processes and/or outcomes for the organization.

  • Collaborate with regional executive director of quality and the use of regional PI staff’s use of the performance improvement methodology to provide PI support to the organization.

  • Work collaboratively with the Accreditation and Licensure area on ongoing survey readiness.

  • Provide comprehensive reports of quality performance improvement activities to the PI teams and Medical Staff, Medical Executive Committee, and the Medical Affairs Committee.

  • Serve as a coach and mentor to direct reports.

  • Maintain professional growth and development through participation in seminars, educational programs, workshops, and professional affiliations.

  • Participate in medical staff, service line , organization meetings as required.


Required qualifications for this position include:

  • Bachelor's Degree in health related field

  • 2 years acute care setting practicing within specified licensure

Preferred qualifications for this position include:

  • Master's Degree

  • 3 years progressive hospital leadership positions

  • Current California Registered Nurse License, or equivalent or higher level licensure or equivalent experience and expertise in quality data analytics strongly

  • Certified Professional in Healthcare Quality CPHQ

About the hospital you will serve.

Nationally recognized for clinical excellence and trauma care, Providence Holy Cross Medical Center is a 377-bed, level II trauma center in Mission Hills, California. We are the only Magnet®Designated Hospital in the San Fernando Valley. Providence Holy Cross also has been recognized this year by the Los Angeles Business Journal as one of the best places to work in Los Angeles. As our reputation for excellence grows, so does our facility. We have recently expanded our medical center with the addition of a new 138 bed patient care wing. This expansion has made Providence Holy Cross Medical Center one of the largest hospitals serving the San Fernando and Santa Clarita valleys.

We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit

Our Mission

As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.

About Us

Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.

Schedule: Full-time

Shift: Day

Job Category: Non-Clinical Lead/Supervisor/Manager

Location: California-Mission Hills

Req ID: 301566