VP - Quality & Performance Improvement

If you are looking to make an impact on a meaningful scale, come join us as we embrace the Power of One!

We strive to be an employer of choice and establish a reputation for being a talent rich organization where Associates can grow their career caring for others. For over a century, we’ve served the health care needs of the people of Memphis and the Mid-South.

The VP of Quality & Performance Improvement is responsible for leading system-wide quality, patient experience, and performance improvement functions to drive measurable improvements in clinical outcomes, patient experience, and operational efficiency across Methodist Le Bonheur Healthcare. Provides executive leadership in the development of a standardized performance improvement infrastructure, establishes system-wide quality priorities based on data analytics, and ensures performance excellence in CMS and value-based programs. Partners with operational, nursing, and physician leadership to advance a culture of high reliability, accountability, and continuous improvement. Model appropriate behavior as exemplified in MLH Mission, Vision and Values.

Working at MLH means carrying the mission forward of caring for our community and impacting the lives of patients in every way through compassion, a deliberate focus on service expectations and a consistent thriving for excellence.

A Brief Overview

The VP of Quality & Performance Improvement is responsible for leading system-wide quality, patient experience, and performance improvement functions to drive measurable improvements in clinical outcomes, patient experience, and operational efficiency across Methodist Le Bonheur Healthcare. Provides executive leadership in the development of a standardized performance improvement infrastructure, establishes system-wide quality priorities based on data analytics, and ensures performance excellence in CMS and value-based programs. Partners with operational, nursing, and physician leadership to advance a culture of high reliability, accountability, and continuous improvement. Model appropriate behavior as exemplified in MLH Mission, Vision and Values.

What You Will Do

• Develop and implement a system-wide quality and performance improvement strategy aligned with organizational priorities. Establish and deploy a standardized performance improvement methodology across all care settings (acute, ambulatory, post-acute)
• Identify and prioritize system quality improvement initiatives based on data, risk, and outcomes impact.
• Lead system-wide patient experience strategy, including improvement in HCAHPS and other experience metrics.
• Oversee clinical quality and process improvement initiatives, including reduction in harm, variation, and inefficiencies. Ensure availability of timely, accurate, and actionable quality data and analytics to support decision-making.
• Maintain accountability for CMS programs and value-based care performance, including Star Ratings and other regulatory metrics.
• Partner with operational, nursing, and physician leaders to align and execute quality improvement initiatives.
• Provide leadership and direction to Quality & Performance Improvement Directors across care sites. Drive a culture of high reliability, safety, and continuous improvement across the organization.
• Support integration of quality priorities into system governance, QAPI, and leadership structures.
• Facilitate the use of quality improvement methodologies and tools to support sustainable outcomes improvement.
• Oversees reporting and communication of quality performance to senior leadership and governance bodies.
• Key Performance Indicators (KPIs):
• Implementation and adoption of a standardized system-wide performance improvement methodology.
• Development and execution of an annual, data-driven system quality improvement priority portfolio.
• Measurable improvement in patient experience scores across acute, ambulatory, and post-acute settings.
• Performance improvement in CMS Star Rating and value-based programs (VBP, HAC, Readmissions).
• Reduction in clinical harm and variation (e.g., PSI-90, mortality, HAIs, LOS).
• Advancement of data accessibility and reporting timeliness for quality performance insights.
• Engagement of physicians, nursing, and operational leaders in quality and performance improvement initiatives.
• Standardization and reliability of improvement practices across all care sites.
• Governance & Organizational Accountability (Dotted-Line Responsibilities):
• Serves as a key executive partner to the System Quality Oversight Committee, supporting performance monitoring, prioritization of improvement initiatives, and escalation of risk and opportunity areas.
• Provides leadership alignment with QAPI (Quality Assessment and Performance Improvement) programs across all facilities and care settings.
• Partners with facility-level Quality and QAPI councils to ensure consistency in performance improvement methodology, reporting, and accountability structures. Collaborates with executive and physician leadership to ensure alignment between system priorities and governance decision-making.
• Supports board and executive reporting on quality, patient experience, and value-based performance.
  
  

Education Qualifications

• Required - Master's Degree Nursing
• Preferred - Master's Degree Public Health
• Preferred - Master's Degree Business Administration
• Preferred - Master's Degree Healthcare Administration
• Preferred - Doctorate
  
  

Experience Qualifications

• Required -
• Minimum of ten (10) years of progressive leadership experience in healthcare quality, patient safety, regulatory, or operational improvement.
• Demonstrated success leading: multi-hospital quality programs, CMS regulatory reporting, HEDIS performance improvement, enterprise performance improvement initiatives.
• Experience working with physicians and executive leadership in matrixed healthcare organizations.
• Strong understanding of: value-based care, population health, healthcare analytics, quality benchmarking, high reliability organizations, and regulatory compliance.
• Preferred - 5-7 years Executive leadership
  
  

Skills And Abilities

• Demonstrated expertise in quality management, patient experience, and performance improvement methodologies.
• Advanced knowledge of CMS quality programs and healthcare regulatory requirements.
• Deep understanding of HEDIS measures and payer quality programs.
• Expertise in quality improvement methodologies and change management.
• Exceptional strategic planning and execution capabilities.
• Strong financial and operational acumen.
• Excellent communication, presentation, and relationship-building skills.
• Ability to influence executive leaders, physicians, and interdisciplinary teams.
• Strong analytical and data interpretation skills.
• Demonstrated ability to lead transformational change across complex organizations.
• Excellent project management skills; coaching and mentoring skills.
  
  

Licenses and Certifications

• Required - Certified Professional in Healthcare Quality-CPHQ - National Association for Healthcare Quality
• Required - Registered Nurse Tennessee - Tennessee Board of Nursing
• Preferred - Six Sigma Yellow Belt - Authorized Six Sigma Certification Issuer
• Preferred - Six Sigma Black Belt - Authorized Six Sigma Certification Issuer
• Preferred - Six Sigma Green Belt - Authorized Six Sigma Certification Issuer
• Preferred - Six Sigma Master Black Belt - Authorized Six Sigma Certification Issuer
• Preferred - Six Sigma White Belt - Authorized Six Sigma Certification Issuer
  
  

Supervision Provided by this Position

• Manages directly or indirectly leaders responsible for:
• o System Patient Experience leader
• o System Quality Data & Analytics leader and team
• o Care Site Quality & Performance Improvement Directors (acute, ambulatory, post-acute)
  
  

Physical Demands

• The physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion.
• Must have good balance and coordination.
• The physical requirements of this position are: light work - exerting up to 25 lbs. of force occasionally and/or up to 10 lbs. of force frequently.
• The Associate is required to have close visual acuity to perform an activity, such as preparing and analyzing data and figures; transcribing; viewing a computer terminal; or extensive reading.
• The conditions to which the Associate will be subject in this position: The Associate is not substantially exposed to adverse environmental conditions; job functions are typically performed under conditions such as those found in general office or administrative work.
  
  

Our Associates are passionate about what they do, the service they provide and the patients they serve. We value family, team and a Power of One culture that requires commitment to the highest standards of care and unity.

Boasting one of the South's largest medical centers, Memphis blends a friendly community, a thriving and growing downtown, and a low cost of living. We see each day as a new opportunity to make a difference in the lives of the people in our community.