Manager, Performance Improvement

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Location: Beverly, MA
Job ID: 170447-1A
Date Posted: Mar 29, 2022
Category: Professional

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Job Description

Welcome To

Welcome to Beverly Hospital, part of Beth Israel Lahey Health. Beverly Hospital is a full service, community hospital providing leading-edge, patient-centered care to North Shore and Cape Ann residents. The hospital provides a full-range of state-of-the-art care and services including primary care, cardiovascular care, surgery, orthopedics, emergency care, maternity, pediatrics, as well as many other specialties. Beverly Hospital is nationally recognized for patient safety as it is one of only 42 hospitals in the United States to be awarded an “A” grade from The Leapfrog Group – the nation’s leading nonprofit watchdog on hospital quality and safety.


Beverly Hospital promotes the culture and philosophy which enables employees to give and receive the best of care. You can become a part of the team that achieves this success through our CREATE values of Community, Respect, Excellence, Accountability, Teamwork and Empathy.


About the Job

Job Summary:

The manager for Performance Improvement is responsible for ensuring the organization is compliant with mandatory and voluntary data collection and reporting requirements at the federal, state, and local levels, such as CMS, MassHealth, TJC, Mass DPH, Maryland Indicators, NDNQI, MHA Patients First, IHI, LeapFrog, Tufts P4P, Blue Cross P4P, Harvard Pilgrim P4P, and BRM as assigned; and, for oversight and coordination of performance measurement and improvement. 


The manager maintains awareness of and develops a plan to respond to changing data collection and reporting regulations and requirements in a timely manner.


The manager ensures that departments throughout the organization comply with data collection and reporting requirements and that the hospital's policies, procedures and practices accurately reflect the most current regulatory agency requirements and compliance with pay for performance quality measures. The manager is responsible for oversight of data management and analysis and the data management staff in the performance improvement department.


The manager assists in development of a comprehensive education plan to educate the workforce, managers, managers, senior leaders and physicians about changing regulatory agency requirements, and performance improvement data, improvement strategies and performance improvement concepts and methods.


The manager provides oversight of the organization's dashboards for clinical quality measures. The manager provides support and assistance to the medical staff with regard to clinical statistics and quality activities including the identification and resolution of quality concerns, coordination and reporting of quality and patient safety data. The manager is responsible for the integrity of data, and provides oversight of data collection, data analysis and data interpretation related to clinical quality monitoring and improvement initiatives. The manager reports to the Director for Performance Improvement.

Scheduled Hours

40 hour, exempt position, day shift.

About Us

Beth Israel Lahey Health is dedicated to improving health and wellness and making a difference in the lives of our patients, their families and all members of the communities we serve.  Formed in March 2019, Beth Israel Lahey Health is a patient-centered, integrated care delivery system providing a continuum of services spanning academic, tertiary and community hospitals, dedicated orthopedic and psychiatric hospitals, primary and specialty care, community acute care, ambulatory care, behavioral services and home health.  Beth Israel Lahey Health Performance Network is a unified joint contracting and population health management organization, jointly governed by participating physicians and hospitals.

Equal Opportunity Employer/Minorities/Females/Disabled/Veterans.


  • Master's Degree in nursing, business, public health, behavioral science or related field.
  • Five years of relevant experience in a health care environment with increasing responsibility.
  • Certified Professional in Healthcare Quality (CPHQ) strongly preferred upon hire, and required within one year of hire.
  • Certified Professional in Healthcare Risk Management (CPHRM) strongly preferred.
  • Proficient in Windows-based operating software and systems that include MS Word, MS Excel, MS Access and MS PowerPoint.
  • Experience in project development, project management and strong analytical skills, including data entry, manipulation, management, and data analysis required.
  • Excellent written and oral communication and presentation skills required.
  • Knowledge of patient quality, safety and satisfaction performance measures and indicators, data definitions and sources and relevant national databases and benchmarks; knowledge of healthcare quality, safety and satisfaction data design, collection, aggregation and summarization; and expert knowledge of performance improvement models, methods and systems required.
  • Ability to work under minimal supervision, ability to adapt quickly to changes within the work environment required.
  • Must be a team player and have proven success applying a team approach and ability to work in conjunction with nurse managers, nurse directors, and staff in a supportive way to troubleshoot and resolve issues. Is able to address difficult situations with tact and diplomacy.