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Director of Performance Improvement (Santa Rosa)

Northern California Behavioral Health System

Santa Rosa, California, United States permanent

Posted: March 23, 2026

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Quick Summary

The Director of Performance Improvement at Santa Rosa Behavioral Healthcare Hospital must develop and implement a systematic program to improve care quality across the hospital, including input on clinical and quality issues, data collection, and leadership for process improvement projects.

Job Description

DESCRIPTION OF POSITION:

Responsible for the development, planning, coordination and administration of a systematic program designed to improve the quality of care across Sant Rosa Behavioral Healthcare Hospital.

KEY RESPONSIBILITIES:

· Provide input on clinical and quality issues and how the organization can make strong cases for improvement in areas such as infections, mitigation of errors, and improved safety culture.

· Maintains all quality data for the organization.

· Create and provide leadership for successful planning and execution of process improvement projects or programs.

· Manage functions, systems, documentation, and procedures for the successful conduct and audit of the process improvement program.

· Oversee the creation of educational resources for improvement initiatives; ensuring sufficient resources are in place to provide expert timely support of the program. Manage these resources to ensure their effectiveness.

· Direct and coordinate a team to implement the Quality Assurance and Performance Improvement (QAPI), patient satisfaction, policy and procedure, and risk management programs.

· Function within the organization as an advocate for continuous improvement, professional development, and as a model for Santa Rosa Behavioral Healthcare Hospital culture and values.

· Improve strategies for driving organizational culture change, and better understand how operational processes within healthcare organizations can be leveraged.

· Participates in activities to enhance professional growth and development.

· Make rounds regularly and be a resource so staff knows who to come to with opportunities for improvement.

· Responsible for reviewing any changes in legislation and regulations impacting the field of healthcare.

· Upholds the Organization’s ethics and customer service standards.

This job description is not intended to be all-inclusive. Employee may perform other related duties as required to meet the ongoing needs of Santa Rosa Behavioral Healthcare Hospital.


Requirements:
POSITION REQUIREMENTS:

Knowledge and Experience:

· Bachelor's degree in a related field required, Master’s degree in a related field preferred.

· Minimum of 3 years’ experience with specific experience and knowledge in the areas of performance improvement, quality assurance, and/or risk management.

· One year of supervision or management experience required.

· Knowledge of psychiatric service delivery system and treatment methods, with specific knowledge and skills in areas of performance improvement or quality assurance.

· Current knowledge of continuous quality improvement methodology.

· Knowledge of applicable standards and regulations.

· Current CPR certification (or obtained within first 30 days of hire).

· Verbal de-escalation and physical intervention program as approved by the CNO.)

Skills and Abilities:

· Maintains confidentiality of patients at all times

· Sensitivity to and willingness to interact with persons of various social, cultural, economic and educational backgrounds.

· Proficiency with software and/or equipment (Microsoft Office applications including Outlook, Word, Excel and PowerPoint.)

· Strong organizational skills with ability to prioritize projects, work relatively independently, manage multiple tasks, and meet deadlines.

· Skilled in data collection, analysis, evaluation and interpretation

· Strong written and verbal communication skills.

· Strong interpersonal skills. Ability to work with people with a variety of background and educational levels.

· Ability to work independently and as part of a team.

· Good judgment, problem solving and decision-making skills.

· Demonstrated commitment to working collaboratively as well as possessing the skills to lead, influence, and motivate others.

· Ability to work in a fast-paced, expanding organization.

· Perform complex mental functions and basic arithmetic functions; interpret complex laws, regulations, and policies; collect, interpret, and/or analyze complex data and information.

Physical Requirements:

While performing the duties of this job, this position is frequently required to do the following:

• Use standard office equipment and computer keyboard with manual and finger dexterity and wrist-finger speed sufficient to perform repetitive actions efficiently for extended periods of time.
• Communicate effectively in person and via telephone in a manner which can be understood by those with whom the person is speaking, including a diverse population.
• Minimum standard of visual acuity with or without correction.
• Hearing within normal hearing ranges
• Reach forward, up, down, and to the side.
• Walk, push, pull, lift, carry objects from a lower to higher position or horizontally from position to position or otherwise move objects.
• Sit or stand for minimum periods of one hour at a time and come and go from the work area repeatedly throughout the day.
• Lift up to (30) pounds, exert up to 100 pounds of force occasionally, and/or up to 20 pounds of force frequently.


Benefits:
• Medical
• Vision
• Dental
• 401(k)
• 3.5 Weeks Paid Time Off
• $25,000 Life insurance policy is provided at no charge to the employee

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