Director Quality Management & Performance Improvement 20K Sign on Bonus

Job Locations US-CA-Los Angeles
Job ID


CHA Hollywood Presbyterian (CHA HPMC) is a nationally recognized acute care facility that has been caring for the Hollywood community and Los Angeles Areas since 1924.


Join our Global Network and be a CHA Global Ambassador

CHA HPMC is also a part of the world-renown CHA Health System (CHS). CHS has CHA University which consists of 14 education institutions including medical school, nursing school and pharmacy. CHA global network operates 81 hospitals and specialty clinics, 30 research and 31 bio/pharmaceutical/healthcare companies with 14,000 employees in seven countries.


Our New Facility is seeking for Top Talents

The best women’s hospital in Los Angeles is looking for current RN candidates to staff Operating Room, Emergency Department, Labor & Delivery and Mother-Baby care units to be housed in our expanding new patient tower facility scheduled to open next year. Come be a part of this dedicated and caring team right in the heart of Hollywood.

Professional Requirements

Job Summary:

Responsible for continual improvement in the quality, safety and satisfaction of care delivery, in the facility and associated clinics. Facilitates performance improvement activities and CQI activities throughout the hospital. Acts as a point of contact to the administrative team, department managers and medical staff. Provides administrative oversight to the infection prevention department.  Will assist in facilitating all regulatory body surveys, i.e., TJC, State Licensing Review, and CMS Validation surveys as needed.

  • Assists in the design, planning, implementation and coordination of Quality Management and Performance Improvement activities for assigned hospital and medical staff departments, committees, divisions, service lines and functions.
  • Proactively coordinates and facilitates performance improvement teams to support key initiatives, including but not limited to, activities focused on clinical quality improvement, patient safety and risk reduction, patient experience, efficiency, FMEAS, and root cause analyses and medical staff improvement (e.g. OPPE, FPPE)
  • Participates in an integral role to ensure compliance with CMS, TJC, Leapfrog, etc., data collection and reporting of process and outcome measures.
  • Facilitates development and implementation of data collection tools and processes including the ability to: identify data elements needed to complete appropriate measurement, perform data collection and abstraction per specifications, and validate data prior to submission or preview reports prior to publication.
  • Facilitates meetings, presents data and reports, identifies key findings and assists with action plans and implementation.
  • Establishes policies and procedures consistent with the Quality and Performance Improvement initiatives and objectives of the facility and ensuring their execution.
  • Evaluates the results of overall performance improvement activities regularly and systematically, and reporting these results to Vice President of Quality as well as executive leadership, Medical Staff and Governing Boarscor
  • Ensures that the responsibilities, authorities and accountability of all direct subordinates are defined and understood
  • Ensures the overall direction, coordination and evaluation of the subordinate units/departments.
  • Collaborates with Vice President of Quality in the development of and supporting performance improvement activities for the facility.
  • Ensures that all organization activities and operations are carried out in compliance with local, state and federal regulations, TJC standards and laws governing healthcare operations.
  • Maintains an environment of collaboration and cooperation among hospital departments.
  • Maintains open lines of communication with subordinate departments.
  • Is responsible for interviewing, hiring, assigning and directing work, counseling, appraising performance, rewarding and disciplining personnel.
  • Demonstrates effectiveness in planning and implementing the performance improvement program to meet the needs of the hospital.
  • Demonstrates knowledge of current performance improvement methodology and practices. Maintains awareness of changes in the regulations and requirements by accrediting bodies.
  • Demonstrates use of database systems to document occurrences, medical staff review functions, committee review and actions. Compiling reports for committees, Governing Board and administrative team.
  • Consults with other departments as appropriate to collaborate in patient care and performance improvement activities.
  • Maintains current knowledge of accreditation and licensing requirements and must be a resource to staff on these regulations in order to improve management of outcomes and ensure compliance.
  • Participates with regulatory readiness and survey preparation activities including mock survey tracers.
  • Provides support and assistance to medical staff officers, committee chairpersons and Governing Body, as required.
  • Utilizes information obtained via performance improvement activities to seek and act on opportunities to improve patient care processes.
  • Consistently demonstrates a professional, self-directed, mature, disciplined and tactful approach to department responsibilities.
  • In consultation with the Human Resources Department and legal counsel, develops disciplinary measures for noncompliance (including the failure to prevent, detect, or report any noncompliance), appropriate to the nature and extent of the deviation, and assuring consistency in the application of disciplinary action.
  • Manage periodic reviews of all standard operating procedures and perform internal audits.
  • Manage and maintain the status of all audit findings and ensure prompt response & resolution.
  • Improve effectiveness, efficiency, reliability, and productivity on a continuous basis.
  • Lead/coordinate investigations, and the development and implementation of corrective and preventative action (CAPA) recommendations.
  • Manage Performance Improvement (PI) activities and projects.
  • Oversee the Quality Committee and PI Teams.
  • Provide summary reports to management of all PI activities.
  • Develops annual Quality Assessment Performance Improvement plan (QAPI), annual evaluation, Key Quality Indicators, reporting calendar and interfaces with cross-functional teams to coordinate the operational support and resources needed to reach quality performance goals.
  • Develops mitigation plans in partnership with operational areas to address performance deficits.
  • Reviews patient charts through a critical lens and evaluates gaps in care for compliance based on measure specifications and to ensure clinical staff are completing tasks per established guidelines.
  • Works with analytic and reporting teams to ensure appropriate reports, performance and data analysis are produced to increase efficacy of performance improvement efforts and to facilitate attainment of quality program goals.
  • Ability to synthesize complex data from multiple sources to inform strategies and create specific deliverables and action plans.
  • Oversee the peer review process in coordination with the Chief Medical Officer.
  • Quality Measures:
    • Responsible for overseeing the data collection and submission for all core measures, public reported data and audits.
    • Develops education for provider partners and internal staff on quality initiatives.
    • Able to accurately identify patients that are eligible for exception and exclusion criteria.
    • Responds to coding, documentation related questions from clients and staff with appropriate information provided in a timely and accurate manner.


Minimum Education

Bachelor's degree in related health care field required.

Graduate of an accredited Registered Nurse Program


Preferred Education

Masters' degree preferred


Minimum Work Experience and Qualifications

Minimum of three years’ experience in an administrative or leadership role.

Highly developed organizational skills.

Demonstrates familiarity with Microsoft Office Software, as well as Outlook.

Demonstrated ability to lead change.

Results driven.

Business acumen.

Ability to build Coalitions.

Ability to communicate effectively verbally and in writing.


Required Licensure, Certification, Registration or Designation

Current CA RN license

CPHQ certification preferred

Valid CA driver's license

Current Fire Card


Salary range is based on years of experience: $153,485 - $198,450 Annually





Disclaimer, Compliance and Service Language:


DISCLAIMER: The above statements are intended to describe the general nature and level of work being performed by incumbents assigned to this job. This is not intended to be an exhaustive list of all the responsibilities, duties and skills required. The incumbent may be expected to perform other duties as assigned.


COMPLIANCE & INTEGRITY: Consistently supports compliance and the Hollywood Presbyterian Medical Center's Code of Conduct by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and licensure requirements (if applicable), and Hollywood Presbyterian Medical Center's policies and procedures.

Models and reinforces ethical behavior in self and others in accordance to the Code of Conduct; adheres to organizational policies and guidelines; supports compliance initiatives; maintains confidences; admits mistakes; conducts business with honesty; shows consistency in words and actions; follows through on commitments.  All Directors, Managers and Supervisors are accountable for communication, implementation, enforcement, monitoring and oversight of compliance policies and practices in their departments.

SERVICE & QUALITY: In addition to defined technical requirements, accountable for consistently demonstrating service behaviors and principles defined by the Hollywood Presbyterian Medical Center, as well as specific departmental/organizational initiatives. Also accountable for consistently demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our patients, and to purchasers, contracted providers and vendors.


WORKPLACE SAFETY: In addition to defined working conditions and physical requirements, employees are accountable for working safely; following established policies & procedures; utilizing all designated protective personal equipment (PPE) and/or safety equipment assigned for task; and reporting all injuries and hazards to their supervisor immediately.  Supervisors and Managers are accountable for ensuring the safety performance of employees; applying consistent practices in compliance with federal, state and local regulations; providing guidance to maintain a safe and healthy work environment.

Hollywood Presbyterian Medical Center is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.

External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, including but not limited to the Los Angeles Fair Chance Ordinances.





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