Director of Quality Improvement - Mile Square Health Center

Position Summary The Director of Quality Improvement provides strategic and operational leadership for the quality improvement and performance management program at Mile Square Health Center. Reporting to the Chief Medical and Quality Officer, the Director is responsible for advancing a culture of continuous quality improvement, evidence-based practice, patient safety, health equity, and accountability for clinical outcomes. The Director leads the development, implementation, monitoring, and evaluation of organization-wide quality improvement initiatives and serves as a key resource for clinical and operational leaders in the use of data to improve patient care and organizational performance. Major areas of responsibility include HRSA Uniform Data System (UDS) quality improvement and reporting, Patient-Centered Medical Home (PCMH) recognition and ongoing requirements, HEDIS and other payer or regulatory quality measures, care gap identification and closure, and other strategic quality initiatives. As a registered nurse by training, the Director brings clinical expertise and a patient-centered perspective to quality improvement while working across disciplines and departments to translate performance data into sustainable improvements in clinical practice and patient outcomes. The Director also provides leadership and oversight for Quality Navigators and other quality improvement staff, establishes performance expectations and workflows, and partners with providers, nurses, care teams, and administrative leaders to achieve measurable and sustainable improvements in quality. Essential Responsibilities Quality Improvement Performance Management Provide leadership and oversight for Mile Square Health Center's quality improvement and performance management program. Develop, implement, and evaluate evidence-based quality improvement initiatives designed to improve clinical outcomes, patient safety, access, patient experience, health equity, and population health. Lead quality improvement activities related to HRSA UDS clinical quality measures, including monitoring performance, identifying gaps, developing interventions, and evaluating outcomes. Provide organizational leadership for PCMH recognition, application, renewal, and continuous improvement activities. Manage the implementation and maintenance of PCMH throughout the Mile Square Enterprise. Leads and manages PMCH transformation and ongoing medical home patient-centered activities. Defines practice organizational structure and staff responsibilities/skill to support key PCMH functions. Supports and trains staff on their roles and responsibilities. Oversee quality initiatives related to HEDIS measures and other payer, state, federal, regulatory, or organizational performance measures, as applicable. Establish systems for monitoring key quality indicators and ensure timely identification of performance gaps and opportunities for improvement. Develop and maintain quality dashboards, scorecards, reports, and other performance management tools. Analyze quality data and trends to identify opportunities for improvement and inform clinical and operational decision-making. Translate performance data into actionable quality improvement plans with clearly defined interventions, responsible parties, timelines, and measurable outcomes. Apply established quality improvement methodologies, including process improvement, root cause analysis, Plan-Do-Study-Act (PDSA), and other appropriate approaches. Monitor the effectiveness, sustainability, and impact of quality improvement interventions and modify strategies as needed. Collaborate with clinical and operational leaders to integrate quality measures and care gap closure into routine workflows. Promote accountability for quality performance while fostering a supportive, learning-oriented environment. Strategic Leadership Organizational Development Serve as a strategic advisor to the Chief Medical and Quality Officer and other organizational leaders on quality improvement, performance management, patient safety, population health, and regulatory priorities. Develop, in collaboration with organizational leadership, annual and long-term quality improvement priorities, goals, and performance targets. Ensure quality improvement activities are aligned with Mile Square Health Center's mission, strategic priorities, and commitment to equitable, patient-centered care. Lead multidisciplinary initiatives that require collaboration across clinical, operational, administrative, and support departments. Build and maintain strong partnerships with physicians, advanced practice providers, nurses, behavioral health professionals, care management staff, quality navigators, analytics staff, and other members of the care team. Establish clear systems for communicating quality priorities, performance results, improvement opportunities, and organizational expectations. Lead or participate in quality, patient safety, population health, and performance improvement committees and workgroups. Provide leadership for organizational readiness related to PCMH, HRSA, quality audits, regulatory reviews, and other quality-related assessments. Identify emerging quality and regulatory priorities and assess their potential impact on Mile Square Health Center. Promote a culture in which staff at all levels are engaged in identifying problems, testing solutions, and improving systems of care. Evaluate quality program effectiveness and recommend changes in priorities, resources, staffing, technology, and workflows to support organizational goals. Represent Mile Square Health Center in appropriate institutional, community, academic, and external quality improvement initiatives and collaboratives. Clinical Quality Patient Outcomes Apply professional nursing knowledge and clinical expertise to the development and evaluation of quality improvement initiatives. Partner with medical, nursing, and other clinical leaders to improve the quality, safe