Director of Performance Improvement and Risk Manager
Company: Mission Community Hospital
Location: Panorama City
Posted on: April 1, 2026
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Job Description:
Director, Performance Improvement and Risk Management POSITION
SUMMARY Under the direction of the Chief Nursing Officer/Chief
Operating Officer, the Performance Improvement and Risk Management
Director is responsible for administrative, technical, and
coordinating support to and for working collaboratively with the
Performance Improvement Council (PIC) in the development,
implementation and evaluation of the Performance Improvement
Program that meets accreditation and regulatory guidelines. He/She
manages and coordinates the Performance Improvement and Risk
Management Programs throughout the organization. In collaboration
with the Medical Staff, Patient Care Services, Nursing, Support
Services and other departments, the Performance Improvement and
Risk Management Director implements performance improvement (PI)
and risk management programs through department-specific and
organization-wide planning, coordinates reports to the Medical
Executive Committee (MEC), PIC, Board of Directors and
accreditation/regulatory agencies. Facilitates the training of
hospital staff in the use of performance improvement tools,
performance initiatives, corrective action plans development and
implementation. Maintains current knowledge of Joint Commission
accreditation standards, California Department of Health (CDPH),
and Centers for Medicare and Medicaid (CMS) regulations. In
addition, the Performance Improvement and Risk Management Director
is responsible for coordinating hospital regulatory and
accreditation survey activities. This position requires providing
administrative standards compliance supervision to departments,
which provide care/service to hospitalized patients in a manner
that demonstrates an understanding of the functional, and/or
developmental age of the individual served. This position requires
the full understanding and active participation in fulfilling the
mission of Mission Community Hospital (MCH). It is expected that
the Performance Improvement and Risk Management Director
demonstrate behavior consistent with the Mission Community Hospital
values and shall support its strategic plan, goals, and direction
of the Performance Improvement and Risk Management Plans. MAJOR
RESPONSIBILITIES SERVICE PERFORMANCE Greets/acknowledges customers
warmly, with a smile, and immediately when they enter
department/unit/area. Asks how the customer may be helped with
interest and concern. Listens attentively, does not interrupt.
Accepts ownership and takes action to resolve customer needs and/or
concerns. Is attentive and responsive to the expectations of
physicians, co-workers and direct reports. Accepts constructive
criticism and modifies actions accordingly. Is generous in
acknowledging a job well done. SERVICE PERFORMANCE (cont.) Uses
words and behaviors that express consideration, concern and
respect. Facilitates and holds staff accountable for meeting
department customer service standards in the performance of duties.
Utilizes telephone skills effectively as outlined in the Star
Service Program. Keeps all private information about staff or
patients confidential. Identifies customers and their service
requirements. Meets or exceeds customer service improvement targets
as demonstrated by dashboards, etc. VALUE ADDED – INCREASES WORTH
OF SERVICE TO MISSION COMMUNITY HOSPITAL Participates in marketing
activities of the Hospital as requested, including but not limited
to committees/task forces, speaking engagements, conducting tours,
Hospital sponsored health fairs. Contributes to marketing materials
such as brochures, newsletters, teaching materials. Participates in
staff recognition activities in ways that reward behaviors
reflecting positively on Mission Community Hospital. Engages in
interdepartmental /multi-department/house-wide process improvement
forums/task forces/committees. Offers and implements solutions to
challenges/problems. Assist with development-related activities
including fund raising programs & activities. Monitors the
marketplace and recommends new and creative business opportunities.
Analyzes targeted existing services and product lines for
cost/benefit and develops appropriate strategies to improve growth
where applicable. Attends/participates in activities that
contribute to professional growth and development. PERFORMANCE
IMPROVEMENT and RISK MANAGEMENT ACTIVITIES Responsible for
coordinating, facilitating and monitoring hospital-wide PI
activities/initiatives including inpatient and outpatient Core
Measure data abstraction, analysis, and committee reporting.
Responsible for coordinating, facilitating, and monitoring patient
satisfaction improvement initiatives, including data reporting to
hospital committees. Responsible for coordinating, facilitating and
monitoring hospital-wide risk management activities/initiatives
including data abstraction, analysis, and reporting. Responsible
for coordinating and facilitating hospital-wide accreditation and
regulatory agency survey preparedness and readiness, which includes
staff and physician education. PERFORMANCE IMPROVEMENT and RISK
MANAGEMENT ACTIVITIES (cont.) Responsible for conducting a minimum
of two failure mode and effects analysis annually and reporting
findings to appropriate senior management and PI committees.
Responsible for conducting and/or facilitating a minimum of four
Root Cause Analysis (RCA) annually and reporting findings to
appropriate senior management and PI committees. Responsible for
coordinating and facilitating peer review activities as needed.
Assures policy and procedure standards comply with local, state,
and federal law and regulatory requirements. Maintains effective
communication within department, division, and with all relevant
colleagues, divisions and Medical Staff. Coordinates/facilitates PI
and risk management activities through appropriate committee
assignments, defined feedback mechanisms, and periodic evaluation.
Provides a climate for PI and risk management goal achievement by
educating and encouraging excellence in practice. Recommends
changes in the administrative policies that conform to
accreditation standards and California/Federal regulations. Develop
and implement department specific policies and procedures.
Responsive and flexible when interacting with other managers /
directors. Submits accurate and timely status reports to senior
management and/or hospital committees. Provides continuous quality
improvement consultative services to all departments including
leadership, medical staff, nursing, and other ancillary departments
to insure the development and implementation of a quality
management process. Orients/provides employee training related to
performance improvement and FOCUS-PDCA methodology at monthly
hospital orientation. Ensures that mechanisms are in place for
ongoing PI and risk management data collection, analysis and
reporting for important processes and outcomes throughout the
organization in order to maintain and improve the quality of
patient care and services. Identifies and reports national/regional
benchmarks or outcomes excellence targets that assist in
identifying/supporting performance improvement opportunities.
Identifies trends and displays opportunities for hospital, medical,
department/unit care and/or service improvement via aggregation of
data, information, and indicators. Uses a disciplined process
improvement method (the FOCUS-PDCA methodology- identifies the
process, barriers to outcomes and corrective action plans) and
performance improvement tools. Oversees the systematic monitoring
and evaluation of patient care and services, as it relates to
regulatory and accreditation compliance, and performance
improvement activities. PERFORMANCE IMPROVEMENT and RISK MANAGEMENT
ACTIVITIES (cont) Assures that process improvement teams and
committees develop strategies (based on their monitoring
activities) to improve patient care outcomes by assuring that
hospital practices reflect the best known science; that best
practices are identified and emulated; that variations in clinical
care processes are reduced; that reversible causes of patient care
complications are identified and reduced or eliminated and that DRG
specific patient outcomes are both measured and continuously
improved, including but not limited to Core Measure indicators,
FEMA, patient safety initiatives, clinical pathways, restraint
management, code blue effectiveness / outcomes, staffing
effectiveness, CDPH corrective actions plans. Responds to CDPH
Statement of Deficiencies and Plan of Corrections within designated
time frame (due date). Responds to Joint Commission complaints
within designated time frame. Monitors QualityNet website for
quality measure and Value Based Purchasing updates. Responds to
QualityNet action items timely. Collects, trends, reports, and
displays baseline and concurrent outcomes data demonstrating
effectiveness of action plans as compared to national/regional
benchmarks or outcomes excellence targets. Recommends
modification(s) to corrective action plans as appropriate Insures
that activities are implemented to resolve defined problems.
Coordinates, manages, and keeps accurate records/files for large
volume of information that includes data collection; aggregation
and display of information; statistics; the dissemination of
information to appropriate committees and personnel; reports;
corrective action plans status / resolution; follow-up activities.
Utilizes opportunities to function as both a designer and initiator
of controlled change as needed or appropriate to restructure
hospital clinical monitoring activities to reflect the vision and
mission of MCH as well as current/anticipated trends. Remains
current concerning industry wide Diagnostic Related Group -
specific best practices and evaluates such best practices for
implementation. Supports and empowers employees to improve quality
of care and/or service. Possess and maintains a working knowledge
of Joint Commission standards, State of California laws and
statutes (e.g., Title XXII), CMS regulations, Medical Staff Bylaws,
policies and procedures, and community standards. Evaluates,
monitors, and sustains compliance with accreditation and regulatory
bodies. Coordinates MCH’s continuous readiness for the Joint
Commission, CDPH and CMS surveys in collaboration with the
Performance Improvement and Operations Committees.
Facilitates/assists with the annual evaluation of the seven
Environment of Care safety plans and revision of the plans.
Performs other duties as related or assigned. COMPLIANCE Ensures
unusual occurrence forms are completed within 24 hours of event.
Completes investigations/assessments thoroughly and timely;
corrective action plans are formulated and implemented. Promptly
reports any suspected or potential violations to laws, regulations,
procedures, policies and practices, and cooperates with
investigations. Conducts all transactions in compliance with all
corporate and medical center policies, procedures, standards, and
practices. Facilitates/fosters compliance with all applicable laws,
regulations, procedures, policies and practices required by the
job, based on the scope of practice of the position. Facilitates
identification and reporting of occurrences of potential liability
to the Hospital. INFORMATION MANAGEMENT Uses information sources
appropriately in department/unit operations. Uses department
specific information systems applications efficiently and
effectively. Accesses and creates department specific information
system application reports. Conducts reality and validation
assessments of data processed by the department. Serves as an
effective resource to IS to ensure accurate entry/updating of
department specific systems applications. Complies with hospital
policies, accreditation agency standards and state and federal
confidentiality requirements related to management of information,
including HIPAA. Obtains necessary training prior to initial
equipment and software use. Uses software at an intermediate to
advanced level. QUALIFICATIONS: High level of knowledge related to
Joint Commission hospital accreditation standards, California
Department of Public Health, and the Centers for Medicare and
Medicaid Services standards and regulations. Current RN licensure
in the state of California; MSN preferred. Three years recent
performance improvement, quality management, and risk management
experience in acute care preferred. Professionals that do not have
a RN license: Bachelor's degree in healthcare administration,
business administration, public health, b iological science; or
doctoral degree in medicine; or Certified Professional in
Healthcare Quality (CPHQ) certification. Professional must have
four or more years recent performance improvement, quality
management, and risk management experience in acute care setting.
Certified Professional in Healthcare Quality (CPHQ) preferred.
Excellent English written/verbal communication skills. Computer
skilled with experience using Microsoft Office software at an
intermediate level. Intermediate to advance level Microsoft Excel
database and statistical analysis skills required. Physical Demands
Physical Requirements : Ability to negotiate physical environment
safely. Ability to completely lift up to 35 pounds. Ability to lift
patients (with assistance from co-workers and/or lifting devices).
Visual Requirements: Ability to translate and understand written
communications. Ability to negotiate physical environment safely.
Hearing Requirements: Ability to understand and translate auditory
communications accurately. Working Conditions : Standard acute care
hospital setting. Standard hospital patient care setting.
Keywords: Mission Community Hospital, Camarillo , Director of Performance Improvement and Risk Manager, Healthcare , Panorama City, California
