Apply structured improvement methodologies (e.g., Lean, Six Sigma, PDSA cycles) to drive and successfully implement measurable outcomes.

Monitor key performance indicators (KPIs), dashboards, and scorecards across designated departments and patient areas of VMC and report findings to leadership and stakeholders.

Conduct meetings to facilitate implementation of improvement activities and initiatives with clinic or department leaders, IT, training teams, policy owners, and relevant committees. Ensure process changes are rolled out in a systematic and comprehensive way and that related processes impacted by the changes are incorporated into the implementation plan.

Conduct meetings in collaboration with hospital leaders to ensure the Patient-Centered Medical Home (PCMH) certification requirements are met. Collect and submit data into databases for Patient-Centered Medical Home and other certifications, including validation to ensure the accuracy of the data.

Oversee the medical center's eligibility for various national recognition certifications and award programs as assigned. Continuously monitor compliance with program standards and collaborate with stakeholders to maintain compliance or implement new workflows and enhancement to ensure future compliance.

Maintain and review Patient Experience survey results, create and edit reports as needed, and update accounts for access to data. Analyze data and identify opportunities for improvements.

Assist with Leapfrog submissions - tracking answers, supporting meetings, and partnering on submission.

Develop and own annual workplan for assigned VMC areas with strategies, tasks, and timelines.

Contribute to the evaluation of the Quality & Safety Program and partner with Quality & Safety staff as it relates to change management and training leaders and staff

Lead Improvement initiatives and workgroups for projects as assigned. Organize meetings, track tasks, and create timelines for projects. Facilitate completion by coordinating across departments, clinics, and/or units.

Assist clinical leaders and Quality staff with performance improvement work as it relates to certifications and strategic priorities.

Maintain a list and update leaders about current process improvement projects status including those requested, in process, or completed.

Collaborate with key stakeholders across the health system to align ongoing performance and process improvement initiatives, methodologies, and programs with organizational goals.

Participate in the development, implementation, review and revision of policies and procedures as they relate to performance improvement initiatives.

Assist with maintaining quality/safety/PI SharePoint site and pages.

Create training and education materials as needed to implement ongoing quality improvement initiatives.

Develop curriculum and lead trainings to provide education on quality improvement tools, methodologies, and best practices.

Perform other duties as assigned.