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Director, Performance Improvement
Company : Prime Healthcare Services
Location : Passaic, NJ, 07055
Job Type : Full Time
Date Posted : 13 January 2026
Overview
St. Mary's General Hospital, located in Passaic, NJ, is a community-based tertiary medical center focused on providing quality, compassionate care. It is an acute care hospital providing a broad range of services including cardiovascular services as well as a comprehensive program for cancer care. The hospital is also a center of excellence for maternal-child health and outpatient behavioral health services. It is the only hospital in Passaic and with over 550 physicians and 1,000 employees, and is one of the largest employers in the county. Every member of the St. Mary's General team is committed to providing respectful, personalized, high-quality care. St. Mary's General Hospital is a member of Prime Healthcare, which has been lauded as a "Top 15 Healthcare System" by Truven Health Analytics. For information, visit www.smh-nj.com.
Responsibilities
The Performance Improvement Director develops, manages and integrates a comprehensive Performance Improvement (PI) Program to achieve unprecedented results in quality, efficiency, safety, satisfaction and value with transparency.
The Managerial oversight responsibility of the Performance Improvement Program is to develop and share best practices for improving performance in quality, safety, perception of care, value and efficiency; to develop/ maintain scorecards for all Service Lines with defining expected outcomes & benchmarks based on Quality, Safety, Satisfaction and Value; to complete Clinical Assessment, Diagnosis and Treatment for the Service Lines. Responsible for coordinating and managing hospital wide performance improvement activities including continued survey readiness. Responsible for oversight of on going publicly reported quality initiatives undertaken by the organization, like Core Measures, Patient Satisfaction, etc. Work collaboratively with Administration and Leadership. Ensures execution and communication of Performance Improvement and Patient Safety activities occurs from the department level to Board of Trustees.
The scope of activities in managing the PI Program, includes creating collaborative customer relationships; planning appropriate group processes; creating & sustaining a participatory environment; guiding the group to appropriate & useful outcomes; building and maintaining professional knowledge; employing evidence-based practice; integrating best research with expertise & patient values for optimal care; working in interdisciplinary teams; application of performance improvement methodologies to minimize waste, decrease errors, increase efficiency and ultimately improve care and appropriate utilization of informatics to communicate, manage knowledge with clinical expertise and patient values for optimal care.
Team facilitation and experience with hospital accreditation standards and survey process preferred. Knowledge of local regulatory standards & OSHA regulations a plus
Qualifications
Education and Work Experience
Pay Transparency
St. Mary's General Hospital offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. Benefits may vary based on employment status, i.e. full-time, part-time, per diem or temporary. A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $79,000.00 to $106,000.00 on an annualized basis. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure.
Employment Status
Full TimeShift
DaysEqual Employment Opportunity
Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf
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Frequently asked questions
A strong background in healthcare, often including a bachelor's degree in a related field, paired with several years of experience in performance improvement, is crucial. Advanced certifications such as CPHQ and skills in data analysis and cross-departmental coordination enhance eligibility for this role.
This position uniquely focuses on integrating quality, safety, and efficiency initiatives across hospital operations. Unlike broader administrative roles, it centers on measurable outcomes and continuous process optimization to elevate patient care and organizational value.
Typical duties include developing performance scorecards, orchestrating hospital-wide quality initiatives, ensuring compliance with healthcare regulations, leading interdisciplinary teams, and facilitating survey readiness to maintain accreditation standards.
Prime Healthcare Services offers a collaborative environment emphasizing transparency and value-driven healthcare. Directors here engage deeply with multi-disciplinary teams and benefit from the organization's recognition as a top healthcare system, enhancing career impact and growth.
Given St. Mary’s role as a community-based tertiary center, this position involves balancing diverse service lines with tailored performance strategies. The hospital’s scale and reputation provide a rich platform for driving meaningful quality improvements.
Annual compensation typically spans from $79,000 to $106,000, reflecting experience, education, and credentials. This competitive range aligns with regional healthcare leadership salaries, inclusive of comprehensive benefits and potential bonuses.
Passaic’s robust healthcare sector, anchored by facilities like St. Mary’s, creates steady demand for leaders skilled in quality enhancement. Candidates with certifications and local regulatory knowledge often find favorable hiring prospects here.
Passaic’s proximity to major highways and public transit options offers reasonable access, though traffic patterns during peak hospital hours can impact commute times. Evaluating local transport routes and flexible scheduling options can optimize daily travel.
Success hinges on analytical prowess, effective communication across clinical teams, and strategic leadership to foster a culture of continuous quality enhancement. Familiarity with evidence-based practices and accreditation processes is also vital.
Institutions prioritize ongoing professional development, encourage accreditation certifications, and maintain active participation in industry forums. Directors often engage in regular training to align strategies with evolving compliance requirements.