Program Manager Performance Improvement

The Program Manager Performance Improvement leads enterprise-wide initiatives to advance clinical quality, patient safety, regulatory compliance, and operational excellence across NCH Comprehensive Health. This role partners closely with clinical, operational, and physician leadership to drive measurable improvements aligned with NCH’s strategic priorities, including clinical reputation, patient experience, and high-reliability organization (HRO) principles. The Program Manager leverages data from various internal and external systems to identify variation, reduce risk, and improve outcomes using structured improvement methodologies. Reports to VP of Quality, Clinical Reputation & Compliance., Other duties may be assigned.

• Facilitates performance improvement initiatives aligned with NCH strategic goals (clinical reputation, quality outcomes, patient experience, and growth).

• Leads cross-functional teams through end-to-end improvement initiatives, applying structured methodologies and driving creative solutions through workflow optimization, automation, and other capabilities to deliver sustainable, measurable outcomes

• Drives change management efforts to ensure successful adoption, stakeholder engagement, and long-term sustainability of process improvements

• Builds organizational capability by coaching, mentoring, and training teams in performance improvement tools, data-driven decision-making, and continuous improvement principles

• Supports improvements in publicly reported voluntary and involuntary data.

• Supports initiatives that enhance NCH’s clinical reputation and rankings.

• Continually monitors rating agencies’ criteria to ensure NCH alignment.

• Investigates to understand inclusion and exclusion criteria as required by various rating agencies.

• Member of various PI teams including Patient Family Advisory Committee, Patient Experience Steering Committee, Patient Safety, and others as assigned.

• Apply Lean, Six Sigma, PDSA, FMEA and HRO principles to improve reliability, reduce variation, and enhance care delivery.

• Continually monitor processes to understand and establish standard work tools.

• Partners with service line leaders (e.g., cardiac, oncology, ortho) to optimize performance and national benchmarking results (e.g., Vizient, CMS Star Ratings).

• Supports initiatives that enhance NCH’s clinical reputation and rankings.

• Utilizes Epic reporting tools, dashboards, and registries to identify performance gaps and monitor outcomes.

• Translates complex data into meaningful insights for clinical and operational teams.

• Supports continuous survey readiness for Joint Commission, CMS, AHCA, and other regulatory agencies.

• Participates in regulatory readiness activities, mock surveys, and corrective action plans.

• Promotes a culture of safety, transparency, and accountability consistent with HRO principles.

• Partners with operations to improve patient experience.

• Identify and eliminate inefficiencies to improve both patient and staff experience.

• Supports or facilitates interdisciplinary PI teams, including nursing, physicians, ancillary services, and administration.

• Coach’s leaders and frontline staff in performance improvement tools and change management.

• Provides training on performance improvement methodologies and data literacy.

• Supports development of a continuous improvement and high reliability culture across NCH.

Do you have experience in Acute care?, Do you have a Bachelor’s degree?, * Bachelor’s degree in Nursing, Healthcare Administration, Public Health, or related field required. Master’s degree (MSN, MHA, MPH, MBA) preferred

• 1 year experience in an acute care hospital or health system environment required.

• Lean Six Sigma Green Belt or Black Belt certification required within one year of hire.

• Experience in healthcare performance improvement, quality, or clinical operations.

• CPHQ (Certified Professional in Healthcare Quality) or CPPS (Certified Professional in Patient Safety) or similar preferred.

• Proficiency in Epic, Excel, and dashboard/reporting tools

NCH is an independent, locally governed non-profit delivering premier comprehensive care. Our healthcare system is comprised of two hospitals, an alliance of 700+ physicians, and medical facilities in dozens of locations throughout Southwest Florida that offer nationally recognized, quality health care.

NCH is transforming into an Advanced Community Healthcare System(TM) and we’re proud to: Provide higher acuity care and Centers of Excellence; Offer Graduate Medical Education and fellowships; Have endowed chairs; Conduct research and participate in national clinical trials; and partner with other health market leaders, like Hospital for Special Surgery, Encompass, and ProScan.

Join our mission to help everyone live a longer, happier, healthier life. We are committed to care and believe there’s always more at NCH - for you and every person we serve together. Visit nchjobs.org to learn more.