Quality & Performance Improvement Manager

Woodbury, MN

Requisition Number: QUALI001915

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Posted on August 9, 2022

Personal Growth. Expansion. Teamwork. Innovation. Be a part of a truly patient-first environment and an organization that cares about their employees. 

In collaboration with the organization’s Leadership and Physician teams, the Quality and Performance Improvement Manager will oversee the collection and dissemination of quality-related data, provide data analytics of quality data, identification and implementation of quality improvement initiatives, patient experience and patient advocacy data and the performance of risk management functions in accordance with the organization’s strategic interests and in the context of Summit’s position within the twin cities orthopedic market. This position will be responsible for ensuring the availability, integrity, and relevance of the quality-related data and insights needed to support sound operational decision making.

This role will primarily have a schedule of Monday through Friday day hours; will travel between Summit locations as needed. Based at Summit Corporate office in Woodbury, MN.


  • Work collaboratively with physicians, executives and operations leadership to identify priorities and strategies for measurement and improvement of clinical or business office/related outcomes to support organization-wide strategic initiatives. Identify, recommend, and manage for organization-wide performance improvement initiatives based on findings gleaned from patient feedback, survey results, surgical outcomes, and other data. Develop and implement benchmarking methodologies and manage reports to compare against organizational and industry standards.
  • Manage processes, staff, vendor relationships, and other activities required for the consistent and accurate measurement and reporting of four core elements of quality/performance improvement:
    • Patient satisfaction including grievances/complaints and patient experience surveying.
    • Clinical/surgical outcomes.
    • Process improvement.
    • Risk management such as incident reporting and board of medical practice complaints.
  • Work with Quality and Performance Improvement team to understand complex data systems and platforms that can provide useful data; creatively identify ways to use existing data and systems to obtain necessary data and
  • Ensure process for consistent and timely delivery of meaningful, relevant, and comprehensible data and reporting to internal stakeholders across various disciplines and levels of management, using effective communication to ensure understanding and elicit change.
  • Work individually with different physician teams, departments, service lines, sites, and disciplines on improvement projects tailored to each area’s strengths and opportunities for growth.
  • Oversee reporting of quality data to external regulatory agencies as required.
  • Assume responsibility for oversight of patient compliance, concerns, complaints and works with the Compliance Officer to resolve. Ensure compliance with CMS regulations including MIPs and other programs related to healthcare quality and improvement initiatives.
  • Work collaboratively with regulatory agencies, payers, patients, the Summit Orthopedics Patient Advocate, and providers as well as the Summit’s internal grievance committee to investigate and resolve patient grievances, board of medical practice complaints, and insurance payer quality concerns.
  • Oversee and develop quality and performance improvement staff.
  • Develop, implement and monitor organizational goals and objectives. Performs research and development of policies, procedures, and systems that support and guide the department and organization to ensure compliance with company and industry standards, as well as applicable healthcare regulations. 

Summit Health ASO, provides administrative and clinical support to our full spectrum of orthopedic care services in our sub-specialty clinics, walk-in care at our OrthoQuick clinics, imaging, bracing, therapy, surgery, and post-surgical stays at our Care Suites. Our expert teams are part of the 1000+ employees who partner to provide quality services and care designed to support a healthier, more active lifestyle.

Summit Orthopedics is committed to providing equal opportunity to all employees and applicants for employment in accordance with all applicable laws and regulations of federal, state and local governing boards and/or agencies.


  • Preferred: Masters in Business Administration
  • Required: Bachelors in Business Administration


  • Required: • Minimum of five years’ experience in healthcare or in a process improvement role that includes: o Complex reporting or analytical process responsibilities. o Communication and use of data to identify opportunities for improvement. o Implementing change management or performance improvement projects. • Demonstrated project management experience. • Experience managing and developing teams of both entry-level and experienced staff. • Sequel experience preferred
  • Preferred: Certified Professional in Healthcare Quality (CPHQ) preferred.
  • Required: Specialized training, education, or professional development in performance improvement methodologies, quality assessment and assurance best practices, and/or regulatory issues relevant to the healthcare industry.