Department: Administration
Hours: Fulltime (1.0 FTE)
Description:
Position Overview:
The Director of Quality & Performance Improvement serves as Floyd County Medical Center’s leader for organizational quality, patient safety, performance improvement, and organizational excellence. This position provides strategic leadership for the organization’s Quality Improvement Program and partners with Executive Leadership, providers, department leaders, and frontline staff to improve clinical quality, patient safety, operational performance, and the patient experience.
Working collaboratively across the organization, the Director translates data into meaningful action by coaching leaders, facilitating performance improvement initiatives, and implementing sustainable process improvements that advance Floyd County Medical Center’s Strategic Plan.
The Director serves as an internal consultant, trusted advisor, and performance improvement leader by fostering a culture of accountability, innovation, collaboration, and continuous improvement throughout the organization. Working closely with the Compliance & Risk Manager, Regulatory & Safety Specialist, and Health Information Management Director/HIPAA Privacy & Security Officer, the Director helps ensure a coordinated, organization-wide approach to quality improvement, patient safety, regulatory readiness, organizational compliance, and continuous performance improvement. While each role has distinct responsibilities, they function as strategic partners in advancing Floyd County Medical Center’s mission, strengthening organizational performance, ensuring regulatory readiness, and supporting organizational excellence.
Leadership Expectations
The Director is expected to:
- Lead through influence, collaboration, and relationship-building rather than positional authority.
- Serve as an organizational coach who develops leaders rather than solves every problem independently.
- Build trusted relationships with providers, leaders, and frontline staff.
- Translate quality data into meaningful action.
- Foster innovation, accountability, and continuous improvement.
- Promote proactive problem-solving and systems thinking.
- Facilitate interdisciplinary collaboration.
- Champion organizational excellence by aligning improvement initiatives with the Strategic Plan.
- Develop leaders capable of utilizing performance improvement methodologies within their own departments.
- Maintain professionalism, integrity, transparency, and respect in all interactions.
Essential Duties and Responsibilities:
Quality Leadership
- Provides strategic leadership for Floyd County Medical Center’s Quality Improvement Program.
- Develops, implements, and evaluates the annual Quality Improvement Plan.
- Establishes organizational quality goals aligned with the Strategic Plan.
- Develops, monitors, and communicates meaningful organizational quality metrics.
- Facilitates the Quality Committee.
- Presents quality dashboards and reports to Executive Leadership, Medical Staff, Quality Committee, and the Board of Trustees.
- Serves as the organization’s resource for quality improvement methodologies and best practices.
- Maintains collaborative relationships with quality organizations including the Iowa Hospital Association, Iowa Healthcare Collaborative, Quality Improvement Organizations, and other professional organizations.
- Prepares the organization’s Annual Quality Improvement Report summarizing organizational performance, accomplishments, opportunities, and progress toward quality goals for Executive Leadership, the Quality Committee, and the Board of Trustees.
Performance Improvement
- Partners with department leaders to improve clinical, operational, and service performance.
- Coaches leaders in the development and implementation of measurable performance improvement initiatives.
- Facilitates multidisciplinary improvement teams.
- Promotes evidence-based performance improvement methodologies throughout the organization.
- Serves as an internal consultant by helping leaders remove barriers and improve systems.
- Supports implementation of strategic initiatives through performance improvement expertise.
- Provides consultation and facilitation to departments in the development, implementation, monitoring, and evaluation of Performance Improvement Plans.
- Build organizational capability by coaching department leaders to effectively utilize performance improvement methodologies within their areas of responsibility.
- Promotes the use of evidence-based performance improvement methodologies (including Plan-Do-Study-Act (PDSA), Lean, Six Sigma, and other continuous improvement tools) throughout the organization.
Patient Safety
- Leads organization-wide patient safety improvement initiatives.
- Oversees the organization’s patient safety event reporting system to ensure events are entered, reviewed, trended, and utilized to identify opportunities for organizational improvement.
- Monitors patient safety indicators and organizational trends.
- Partners with department leaders, the Compliance & Risk Manager, and the Regulatory & Safety Specialist to ensure significant patient safety events are appropriately reviewed, corrective actions are implemented, and organizational learning occurs.
- Facilitates or co-facilitates Root Cause Analyses in collaboration with the Compliance & Risk Manager and Regulatory & Safety Specialist, department leaders, and Executive Leadership, as appropriate.
- Collaborates with leadership to develop sustainable corrective action plans.
- Evaluates the effectiveness of improvement efforts.
- Promotes a Just Culture and organizational learning following patient safety events.
- Collaborates with clinical leaders to support compliance with National Patient Safety Goals and other evidence-based patient safety standards.
Patient Experience
- Leads organization-wide patient experience improvement initiatives.
- Oversees the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) program.
- Partners with the organization’s patient experience vendor to ensure accurate data collection, meaningful reporting, and implementation of improvement strategies.
- Partners with leaders to improve communication, responsiveness, discharge planning, and the overall patient experience.
- Utilizes patient experience data to drive measurable improvements.
Regulatory Collaboration
- Partners with the Regulatory & Safety Specialist to support continuous organizational readiness for Centers for Medicare & Medicaid Services (CMS), Iowa Department of Inspections, Appeals, and Licensing (DIAL), and other accreditation or regulatory surveys.
- Collaborates with the Compliance & Risk Manager and Regulatory & Safety Specialist to ensure quality improvement initiatives support regulatory compliance and organizational excellence.
- Assists department leaders in addressing quality-related findings identified through surveys, audits, and readiness assessments.
- Integrates regulatory findings, patient safety events, and quality data into organization-wide improvement initiatives.
- Maintains current knowledge of healthcare quality standards, CMS quality programs, and evidence-based improvement practices.
Quality Analytics & Reporting
- Oversees collection, validation, analysis, and interpretation of quality data.
- Develops meaningful dashboards that support organizational decision-making.
- Identifies trends and opportunities for improvement.
- Communicates quality outcomes to Executive Leadership, Medical Staff, applicable committees, and the Board of Trustees.
- Utilizes data to drive performance improvement initiatives.
- Ensures the timely collection, validation, analysis, and submission of required quality data to CMS, state agencies, accrediting organizations, and other regulatory entities.
Strategic Leadership & Collaboration
- Serves as Floyd County Medical Center’s internal consultant for quality and performance improvement.
- Partners with Executive Leadership to advance strategic organizational priorities.
- Maintains a visible presence throughout the organization through departmental rounding and collaborative engagement.
- Collaborates closely with the Compliance & Risk Manager and Regulatory & Safety Specialist to ensure organizational priorities remain aligned.
- Collaborates with the Health Information Management Director/HIPAA Privacy & Security Officer regarding documentation integrity, information governance, privacy considerations impacting quality initiatives, and organizational quality reporting, as appropriate.
- Builds relationships that promote accountability, innovation, and organizational excellence.
- Performs additional leadership responsibilities consistent with the strategic purpose of the position.
Assumes other duties and responsibilities that are related and appropriate to the position and area. The above responsibilities are a general description of the level and nature of the work assigned to this classification and are not to be considered as all-inclusive.
What Success Looks Like
Success in this role is measured by the Director’s ability to strengthen organizational performance through collaboration and measurable improvement.
The successful Director will:
- Advance Floyd County Medical Center’s journey toward CMS Five-Star quality performance.
- Improve patient experience through measurable improvements in HCAHPS and other patient satisfaction metrics.
- Reduce preventable patient harm through sustainable patient safety initiatives.
- Improve organizational performance by coaching leaders and facilitating measurable improvement initiatives.
- Support strategic priorities through quality improvement expertise.
- Foster a culture in which continuous improvement becomes an organizational responsibility rather than the responsibility of one department.
- Develop a culture in which department leaders utilize data to drive decision-making and continuous performance improvement.
Minimum Qualifications:
Education
- Bachelor’s degree in Nursing, Healthcare Administration, Public Health, or another healthcare-related field required.
- Master’s degree preferred.
Experience
- Progressively responsible healthcare experience in quality improvement, patient safety, accreditation, nursing leadership, healthcare operations, or a related field required.
- Leadership experience preferred.
- Experience in healthcare quality improvement, patient safety, accreditation, and performance improvement required.
- Experience leading multidisciplinary improvement initiatives preferred.
Leadership Competencies
The successful candidate will demonstrate the ability to:
- Build trusted relationships.
- Lead through influence rather than authority.
- Coach and develop leaders.
- Think strategically while executing operationally.
- Translate data into action.
- Communicate effectively with all levels of the organization.
- Demonstrate integrity, professionalism, and sound judgment.
- Manage multiple priorities.
- Foster innovation, accountability, and continuous improvement.
- Influence and facilitate organizational change through collaboration, coaching, and relationship-building.
Additional Qualifications:
- Maintains the highest level of confidentiality and professionalism when handling Protected Health Information (PHI), employee information, quality data, and other sensitive organizational information. Demonstrates knowledge of the Health Insurance Portability and Accountability Act (HIPAA) requirements and applicable privacy regulations.
- Advanced computer skills, including proficiency with Microsoft Office Suite (Excel, Word, PowerPoint, and Outlook), electronic health record (EHR) systems, quality improvement software, and data analytics/reporting tools. Ability to analyze, interpret, and present complex data through spreadsheets, dashboards, and reporting applications.
- Demonstrates strong critical thinking, problem-solving, and decision-making skills.
- Demonstrates initiative, adaptability, and the ability to independently lead projects and organizational improvement efforts.
- Ability to effectively utilize technology and data systems associated with quality and performance improvement activities.
- Service-oriented mindset with a commitment to professional growth, collaboration, and continuous learning.
- Ability to support organizational priorities outside of regularly scheduled hours as needed.
- Mandatory Reporter certification required within six (6) months of hire.
- Must be able to read, write, comprehend, and verbally communicate in English fluently.
Licensure/Certification Required:
- Current Iowa Registered Nurse license required if qualifying degree is in nursing.
- Certified Professional in Healthcare Quality (CPHQ) preferred.
- Lean or Six Sigma certification desirable.
Physical Requirements:
- Sit: Frequent
- Stand: Frequent
- Walk: Frequent
- Lift:
- 10 pounds: Frequent
- 25 pounds: Occasionally
- 50 pounds*: Occasionally
- 75 pounds*: Never
- Greater than 100 pounds*: Never
- Carry:
- 10 pounds: Frequent
- 25 pounds: Occasionally
- 50 pounds*: Occasionally
- 75 pounds*: Never
- Greater than 100 pounds*: Never
- Push/Pull:
- 10 pounds: Occasionally
- 25 pounds: Occasionally
- 50 pounds*: Occasionally
- 75 pounds*: Occasionally
- Greater than 100 pounds*: Occasionally
- Squat/Kneel/Crouch: Occasionally
- Climb: Occasionally
- Balance: Occasionally
- Twist: Occasionally
- Bend/Stoop: Occasionally
- Crawl: Never
- Grasp/Grip: Frequent
- Talk: Constant
- Hear: Constant
- See: Constant
- Anything greater than 50 pounds – assist of two or more, or mechanical lift are required.
Environmental Factors:
- Works primarily in a professional office and healthcare environment.
- May be exposed to communicable diseases due to working in a healthcare setting.
- May enter patient care and clinical areas to assess processes, facilitate improvement initiatives, and collaborate with staff.
- Works in a well-illuminated, climate-controlled environment.
- Moderate noise levels may occur due to routine office activity, meetings, and healthcare operations.
- May occasionally encounter blood, body fluids, or other potentially infectious materials when present in clinical areas; appropriate precautions must be followed.
Organizational Relationships:
Reports to: Chief Nursing Officer (CNO)
Works Closely With:
- Chief Executive Officer (CEO)
- Executive Leadership Team
- Medical Staff
- Department Directors
- Compliance & Risk Manager
- Regulatory & Safety Specialist
- Infection Prevention
- Human Resources
- Regulatory Agencies
- Professional Organizations
Employees supervised: None
