Job Description
JOB TITLE: Manager, Performance Improvement
SUPERSEDES: 02/19, 12/23
FLSA: Exempt
JOB CODE: 3261
ISSUED: 02/2019
REVISED: 03/2026
BASIC FUNCTION AND RESPONSIBILITY
The Manager, Performance Improvement is responsible for the leadership of organizational performance improvement activities for MU Health System, ensuring alignment of these activities with the healthcare system's strategic priorities, and quantifiable improvements in patient healthcare delivery.
ESSENTIAL FUNCTIONS
Prioritize performance improvement activities at the organizational and service line levels to align with MU Health System strategic priorities, informed by surveillance of internal performance and risks, as well as current and emerging external performance priorities for clinical value. Establish and maintain cooperative working relationships in cross-departmental project teams.
Design, implement, sustain, and improve consistent quality management systems and methods. Evaluate the effectiveness of improvement structures and processes and make modifications to ensure the achievement of organizational goals.
Supervise prioritized performance improvement initiatives and performance improvement staff, ensuring that clinical and financial results achieve organizational and service line performance goals within established timelines.
Collaborate with patient care leaders to assess literature-based best-practice models for clinical value improvement. Develop and implement process changes based on best practices. Coach and refine process and behavioral changes within healthcare teams.
Establish and oversee evaluation plans to monitor process adoption and performance by healthcare team members. Ensure reports with targets provide immediate performance feedback to the patient care team and include aggregated results to health system leaders. When targets are met, implement effective changes across other relevant patient groups/clinical teams.
Disseminate performance improvement and clinical outcomes externally to strengthen the impact and enhance the reputation of MU Health System.
Lead a culture of safety through proactive risk mitigation and continuous quality improvement, taking measures to routinely evaluate regulatory readiness. Monitor and analyze safety and performance metrics to identify trends and implement corrective actions for staff and/or patients as appropriate.
Manage the development, coordination, and maintenance of daily staffing schedules to ensure the appropriate level of coverage and continuity of care.
Monitor and oversee time and attendance in alignment with MU Health Care policies and practices, ensuring accuracy of records and timely approval for payroll purposes.
3261h-Manager,PerformanceImprovement02/05/2026May complete unit/department-specific duties as outlined in department documents.
KNOWLEDGE, SKILLS AND ABILITIES
Strong analytical and presentation skills.
Knowledge of unit workflows, policies, and procedures to manage daily operations, maintain standards, and support quality improvement.
Applies leadership and interpersonal skills to supervise staff, foster collaboration, and drive accountability and service excellence.
Uses foundational budgeting and compliance knowledge and skills to manage resources, quality program compliance, and support survey readiness.
SUPERVISION RECEIVED
Supervision is received from the Director, Quality Improvement & Patient Safety, or designee.
SUPERVISION EXERCISED
Supervision is exercised over professional, clinical, support staff, students, volunteers, and subcontractors.
REQUIRED QUALIFICATIONS
Bachelor's degree in nursing, healthcare administration, or a related field.
Five (5) years of directly related experience in a healthcare setting.
PREFERRED QUALIFICATIONS
Experience in academic healthcare.
Leadership experience in patient safety or healthcare quality improvement.
Master's degree in nursing, engineering, health management, business, or a related field.
--Black Belt certification in Lean/Six Sigma; or
--Certification for Certified Professional in Healthcare Quality (CPHQ) by the National Association for Healthcare Quality (NAHQ); or
--Certified Professional in Patient Safety (CPPS) by the Institute for Healthcare Improvement (IHI).
Additional license/certification requirements as determined by the hiring department.
PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met with or without reasonable accommodation. The performance of these physical demands is an essential function of the job. This position is very active and requires ambulating, reaching, and moving objects weighing up to and over 20 lbs.
This role also routinely comes into contact with patients who may have contagious illnesses. This position is in a health care facility open 24 hours a day, 365 days a year. Rotating shifts as well as holiday and work during inclement weather will be required.
PERFORMANCE EXPECTATIONS
This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job; however, completion of these duties is a measure of successful performance. Employees of this job classification are subject to performance reviews. Basic functions, responsibilities and characteristics duties may change at any time with or without notice.
SAFETY SENSITIVE STATUS
This position is considered safety sensitive.
This document is a general description of typical job duties, responsibilities and qualifications of employees holding the associated job title. Additional duties, specific qualifications and work emphasis may vary between individual positions.