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Manager, Performance Improvement & Accreditation

Milton, Massachusetts

Organization Facility: Beth Israel Deaconess Hospital Milton Category: Quality Job ID: JR37734 Date posted: 11/30/2023
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When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

Job Type:


Scheduled Hours:


Work Shift:

Day (United States of America)


Under the direction of the Director, Health Care Quality and Patient Safety, the Manager, Clinical Quality Performance Improvement and Accreditation is responsible for the ongoing design, development, and implementation of the hospital’s Quality Assessment Performance Improvement (QAPI) and Patient Care Assessment (PCA) plans. The manager is also responsible for hospital regulatory and accreditation activities, including but not limited to the Joint Commission, The Department of Public Health etc. as well as federal/commercial payer Value Based Purchasing/Pay for Performance and Penalty programs.

Following the principles of high reliability, this individual will identify, evaluate, make recommendations and work closely with other departmental, hospital and hospital system leaders for the implementation of performance improvement (PI) efforts that mitigate actual and potential harm in the delivery of care to patients as well as optimizing hospital performance with external reputational and reimbursement programs. The Manager, Clinical Quality Performance Improvement and Accreditation will work with clinical and non-clinical staff to support, educate, mentor and guide hospital wide and departmental specific strategies relating to PI and Accreditation.

As assigned by the Director, Health Care Quality and Patient Safety, the manager works closely with medical leadership and other healthcare quality department staff to develop, monitor and support medical staff focused and ongoing physician perfromance evaluation processes.


· Coordinates the Hospital-wide Performance Improvement Program.

· Oversees hospital and system wide key performance improvement initiatives.

· Facilitates the medical staff components of the program in conjunction with the Director, Healthcare Quality and Patient Safety.

· Assists in facilitating quality improvement teams assuring the implementation of strong quality improvement strategies using proven quality methods, tools/techniques.

· Plans and actively participate/leads Performance Improvement and Accreditation activities within established hospital committee structure.

· Consults with and assists key stakeholders in establishing and implementing best practices based on research and data analysis.

· Promotes, plans, designs, coordinates and evaluated training and educational activities for all staff in relation to PI and accreditation activities.

· Monitors and takes action to ensure hospital-wide compliance with regulatory and accrediting agencies (i.e. Joint Commission, CMS, and DPH etc.) to ensure ongoing survey readiness.

· Facilitates and coordinates hospital-wide data collection, measurement, trending and dissemination of information regarding regulatory standards and compliance.

· Informs all management levels regarding current developments and changes in regulatory standards.

· Initiates, coordinates and supports necessary changes or action plans and hospital-wide and department-specific performance improvement projects to support regulatory agency standards.

· Collaborates with and assures the integrity and confidential treatment of medical staff credentialing, performance improvement and peer review functions.

· Maintains industry knowledge on quality and performance excellence and innovation as well as accreditation standards and regulations.

· Collaborates with key stakeholders to enhance patient experience and staff engagement.

· Provides project guidance to operational project leaders and sponsors. Analyzes projects and provides recommendations to senior management and /or department leaders to assess organizational potential and strategic alignment. Participates in organizational Committees as assigned.

· Collaborates with others to develop and execute redesign and performance improvement models. Identifies strengths and weakness of teams and learning opportunities for individuals and teams.

· Facilitates the documentation of process flows (current/future state). Designs data collection methods and data analyses to support team efforts.

· Participates with leadership to distinguish areas for performance improvement and facilitates system design to implement best practices aimed at enhancing quality and patient safety.

· Identifies and documents strategies, objectives, timetables, expected outcomes and measures.

· Provides ongoing project management, and ensures that plans are implemented and kept on schedule and budget, ensuring follow-through by key players, and sustaining momentum needed to drive projects to completion. Mentors team leaders and teams.

· Complies with BID-Milton's Code of Conduct, and performance standards relating to service excellence.

· Attends appropriate and mandatory in-service and continuing education training program(s) for hospital staff, commensurate with job responsibilities. Completes all mandatory requirements within defined timeframe for completion.

· Employee maintains competencies (position specific and hospital-wide) required for the specific patient population served.

· Performs all duties in accordance with safety and other laws, rules, and regulations set forth by appropriate regulatory and government agencies and in accordance with established department and hospital policies and procedures.


· Minimum educational requirement: Registered nurse with graduate level degree in Health Care related field required. Undergraduate or higher-level nursing degree required.

· Minimum experience: At least five years of progressive clinical, leadership in an acute healthcare setting.

· Experience in any of the following Performance Improvement, Patient Safety, Healthcare Quality and/or Regulatory Safety.


· Excellent verbal and written communication, interpersonal, organizational, prioritization, critical thinking, problem resolution and program management skills.

· Knowledge of federal and state regulations and standards relating to accreditation and compliance expectations (preferred).

· Knowledge of basic research and investigation techniques with an ability to interpret data, prepare reports, and propose solutions to performance improvement opportunities.

· Demonstrated advanced ability in the use of word processing, presentation and data base software and office products.

· Ability to independently prioritize work projects and to comply with established/required deadlines.

A Physical Abilities Job Description is a component of this Job Description

The above statements are intended to describe the general nature and level of work being performed. This list is not to be construed, as an exhaustive list of all responsibilities, duties and skills required of personnel so classified.

Job Description:

FLSA Status:


As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more about this requirement.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled

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Why join Beth Israel Lahey Health?

If you’re looking for a career where you can make a difference and explore your potential, Beth Israel Lahey Health is the place you belong. Our system includes a network of hospitals, physician practices, outpatient centers, and other healthcare facilities and we offer a broad range of careers in direct patient care, environmental services, registration, finance and many other fields. We are focused on providing compassionate and personalized healthcare with a strong reputation for clinical excellence and research and offer diverse opportunities for career growth and development. Conveniently, we have many locations in communities across Eastern Massachusetts and Southern New Hampshire.

At Beth Israel Lahey Health, we see you for all that you are – your experience and your dreams. Explore our open opportunities and find out why so many have already chosen to join our team.

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Learn more about working at Beth Israel Deaconess Hospital Milton.