Director of Quality Improvement

York, PA | Professional | Tracking Code: 75528

Job Description:


Under the general direction of the Senior Director-Quality, collaborates with System-wide hospital entities, ambulatory practices, independent providers and System resources to ensure that quality and performance improvement activities, metrics and goals are identified, developed, coordinated, improved, measured, evaluated and reported across System-wide Service Lines. Identifies, develops and directs implementation of best practices for clinical excellence and patient care quality for the scope. Offers strategic direction and leadership to achieve quality excellence. Expert at national quality measures and related accreditation requirements. Leads, coordinates and connects System quality plan and reporting, and initiatives and planning for their scope, directing and supervising all dedicated quality improvement staff. Supports the purpose of the Quality Model. Ensures a standardized communication process for strategy and engagement. Creates a model design that bridges multiple entities within the continuum for the Service Line for easier identification of process/policy gaps and differences and related reporting and discussion with the goal of continuous improvement and early identification of risk. Shares and spreads best practice processes, using Lean methodology inclusive of A3 problem solving, LDM improvement methodology, and standard work. The position collaborates with leaders of facilities, programs, and resources across WellSpan to ensure organizational awareness, successful implementation, ongoing maintenance and optimization of enhanced clinical outcomes, increased clinical reliability, and decreased performance variation.


Duties and Responsibilities



  1. Provides direction and supervision of all dedicated Service Line quality staff operating under Corporate Quality.
  2. Provides System direction and coordination of the quality activities for the Service Lines within their scope.
  3. Communicates system work regarding quality improvement and integrates system focus and report planning into quality improvement initiatives.
  4. Leads the appropriate multidisciplinary teams to prepare measures and related results to assign priority recommendations for Service Line and executive leadership decision making.
  5. Develops or revises policies and procedures necessary to support quality improvement.
  6. Develops and coordinates educational initiatives to ensure appropriate quality interpretation. Assists with education efforts of the Hospital's/System's employees regarding quality related activities.
  7. Works collaboratively with hospital leadership, physicians, nursing, ancillary staff, and other key departments such as Clinical Improvement, Performance Improvement, Patient Safety, Population Health, Data Analytics, Infection Control, Patient Experience, Accreditation/Compliance, Regional Medical Directors, and Service Line Vice Presidents.
  8. Manages, and is the subject matter expert for, service line quality measures and external recognition standards/ requirements, including the provision of clinical recommendations for performance improvement based on past, present and projected results.
  9. Oversees the creation of timelines and deliverables for workflow development, implementation and monitoring for selected quality measures.
  10. Tracks performance relative to national benchmarks providing feedback/data to leadership and guidance toward effective performance improvement interventions.
  11. Understands opportunities for improvement in value-based care models and works to implement best practices supporting these. Examples include understanding assigned patient utilization trends, average patient illness severity factors, drivers of social determinants of health barriers, unwarranted clinical variation trends, and inefficient spending patterns.
  12. Teaches appropriate stakeholders how to collect and maintain appropriate metrics, values and specific contract requirements related to pay for performance incentive plans for risk contracts and government-based programs that impact WellSpan entities
  13. Leads the appropriate multidisciplinary teams to prepare measures and related results to assign priority recommendations for Service Line and executive leadership decision making.
  14. Acts as a dedicated quality resource and subject matter expert for the Service Lines in their scope.
  15. Directs activities in line with the Inpatient/Outpatient Quality continuum.





Minimum Experience:

More than 5 years’ experience in health care and health care system administration, and in roles of progressive healthcare quality leadership/management responsibility. Experienced with the national guidelines that produce quality measures and accreditation standards and the related audit processes.


Minimum Education:

Bachelor’s Degree


Minimum Field Of Expertise:

Health care system administrative expertise


Preferred Education:

Master’s Degree or MBA


Required Certification:

Registration and current RN license in PA; CPHQ



Fraud Notice: Please be aware of potentially fraudulent job postings on other websites or suspicious recruiting email or text messages that attempt to collect your confidential information. If you are concerned that an offer of employment with WellSpan Health might be a scam, please verify by searching for the job posting on or contact us at

Ed Pritchard
Ed Pritchard
Sr. Talent Acquisition Consultant
Best of the Best Awards
Similar Opportunities

Why WellSpan Health?

WellSpan Health is an integrated health system that serves the communities of central Pennsylvania and northern Maryland. The organization comprises a multispecialty medical group of more than 1,600 physicians and advanced practice providers, a regional behavioral health organization, a home care organization, eight respected hospitals, more than 20,000 employees and 200 patient care locations. WellSpan is a charitable, mission-driven organization committed to exceptional care for all, lifelong wellness and healthy communities. We are committed to transforming the health of the communities we serve and to educating the next generation of clinicians, staff and leaders.

Employment Benefits

  • Sign-on incentives for new employees (click here for details)
  • Medical, dental and vision insurance
  • Life and accidental death insurance
  • Supplemental life insurance
  • Retirement savings plan
  • Paid time off (PTO)
  • PTO bridging
  • Short-term disability
  • Educational assistance
  • Forgivable loan
  • Flexible spending
  • Credit union
  • Employee recreational activities
  • Childcare
  • Complimentary medicine discounts

Diversity & Inclusion

Welcome. Respect. Value.

Wellspan Health believes that diversity includes all the human characteristics that make each of us similar as well as different. We strive to make every person feel welcomed, respected, and valued while creating a safe and inclusive environment where we all have the individual freedom to express our uniqueness in a respectful manner.

WellSpan Health is an Equal Opportunity Employer. It is the policy and intention of the System to maintain consistent and equal treatment toward applicants and employees of all job classifications without regard to age, sex, race, color, religion, sexual orientation, gender identity, transgender status, national origin, ancestry, veteran status, disability, or any other legally protected characteristic. WellSpan Health does, however, have a tobacco-free/nicotine-free hiring policy.

Quality of Life

Founded in 1741, the city of York is considered by many as the first capital of the United States. The Articles of Confederation were signed by the Second Continental Congress here in 1777. Its beautifully restored historic district is an architectural treasure. While York retains its farming and manufacturing heritage, at its heart York is a thriving cultural community that has attracted creative talent and innovative entrepreneurial investors from across the nation.

Life in York County offers affordable housing, options for higher education, a thriving arts and cultural community, historical attractions, parks and recreational resources, semi-professional baseball team, fine dining and more — within an easy drive of major East Coast cities.

York County residents can find local employment in healthcare, manufacturing, technology, agricultural and service sectors. (Patient population: 445,000)