Executive Director, Quality and Performance Excellence

St. Mary's Healthcare Amsterdam   Amsterdam, NY   Full-time     Quality Control
Posted on February 6, 2024

Job Requisition: REQ 2380
Employment Type: Full-Time 
Shift: Days
Hours Per Week: 40 hours 

Hiring range: $95,950.40-$143,915.20 

The actual compensation for this position will be determined based on experience and other factors permitted by law.


Quality and Performance Improvement Planning and Strategy: Formulates implements and manages a continuous Performance Improvement Plan for SMH across its continuum of care through engagement with medical staff, clinical and administrative staff and the governing body Assesses and enhances procedures and processes toward improving the quality and safety of patient care. With the guidance of the VP, Chief Medical Officer leads, and facilitates service and clinical enhancements as needed to maintain or achieve a safe and high reliable patient care environment that results in exceptional clinical outcomes. Prioritizes quality initiatives, establish relevant and appropriate metrics, and assign timelines and accountabilities. Patient Safety Leadership: Serve as the hospitals Patient Safety Officer by implementing strategies and initiatives to promote patient safety, assess the efficiency of patient safety measures and provide leadership support through collaboration to further the culture of safety. Quality Metrics: Actively manages and ensures that the organization attains the highest recognition on all publically reported metrics. Successful compliance with acute and ambulatory pay-for-performance programs, including CMS and private carriers, to achieve the maximum financial return for the organization.


Provides leadership in the day-to-day operations of risk management, quality support services, infection prevention, and regulatory compliance. Communication and Education: Provides guidance, consultation and education to the Board of Directors, Executive Leadership team, Medical Staff, leadership colleagues, and clinical and non-clinical staff regarding performance improvement, quality and risk management. Communicates the goals, objectives of the hospital’s quality/performance excellence and patient safety plan. Serves as a content expert, facilitator and coach to assist clinical and administrative leaders in moving an agenda of quality/safety/high reliability to the forefront across the organization and to proactively position the organization for accountable care and values-based payment. External Relationships: Acts as the organizational liaison to state and national organizations and other healthcare facilities and enterprises on issues of quality and performance improvement. Human Resource Management: Directs and leads the personnel management activities of assigned areas; guides subordinate leaders in the selection, hiring, training and development of staff. Consults with Human Resources to develop programs and initiatives that that promotes quality and emphasized a high reliability work environment. Financial Management: Directs and participates in the preparation and administration of operating and capital budgets; evaluates staffing, technology, equipment, and supply needs while preparing justifications and cost benefit analyses for those needs. Oversees the procurement of supplies and equipment specific to the Quality program.

 Additional Responsibilities:

Infection Prevention: Maintain a strong working and collaborative relationship with Infectious Disease physician lead and the Infection Control Practitioners to ensure continued success in prevention of harm and program goals and objectives. Medical Staff Affairs: Provides medical staff, especially employed physicians, with on-site clinical and  operational consultations surrounding safety, risk, data analytics and legal affairs including utilization of data systems that support quality improvement efforts. Regulatory Compliance: Maintain a strong working and collaborative relationship with regulatorydepartment to ensure overall compliance. Support advancement of the design and execution of the overall organization-wide program. Monitors and evaluates new or revised regulatory agency and industry laws, regulations, and standards applicable to assigned areas and ensures that assigned activities comply with all requirements. Assures compliance with the regulatory agencies impacting the quality and safety programs including the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC) and New York State (NYS).

Education, Training & Experience:

Bachelor’s Degree in Healthcare Administration, Business, Nursing, Management or a related field required. Master’s Degree or active enrollment in a Master’s program as described above required. RN or other clinical professional degree preferred. Minimum of five (5) years progressive hospital/healthcare system operations and/or leadership experience as well as a strong, demonstrated track-record in healthcare performance improvement. Minimum 5 years in a leadership position, manager or director level required. Certification in Quality and/or Safety such as Certified Professional in Healthcare Quality (CPHQ) or Certified Professional in Patient Safety (CPPS) preferred, or obtained within 2 years. Mastery of performance improvement, safety and change management methodologies and tools including Root Cause Analysis (RCA), Failure Mode Effect Analysis (FMEA). Plan, Do, Study, Act (PDSA), Microsystems, Team Training and Lean. Prior experience with Baldrige or other National Performance Excellence platform highly desirable.

Required Skills, Abilities and Attributes:

Possesses thorough understanding and knowledge of The Joint Commission and CMS standards.Knowledge of New York State DOH and OMH preferred. Excellent communication skills, both written and verbal. Ability to work collaboratively with diverse constituents including staff, leaders, medical staff and the community. Possess a working knowledge of and effectively able to use Microsoft products and other computer-based programs as needed. Demonstrates a thorough understanding of general financial principles and procedures pertaining to budget development, monitoring and justification. Demonstrate Effective problem-solving skills. Able to perform high level conceptual analysis, formulate plans and implement, Able to summarize and prepare complex reports, memoranda, and other written materials, Understand, interpret, and apply laws, rules, regulations, and policies related to assigned areas, Demonstrates commitment to customer service. Proven/demonstrated leadership, communication, and team-building abilities. Ability to develop, lead, manage, coordinate, and drive cross-functional teams to successful project outcomes.

St. Mary's Healthcare Amsterdam

427 Guy Park Avenue
Amsterdam , NY