The Manager, Pharmacy Performance Improvement leads and supports system pharmacy performance improvement initiatives across Baptist Health System Hospitals, Hospital Outpatient Departments (HOPDs), Ambulatory Surgery Centers (ASCs), and Free-Standing Emergency Departments (FSEDs). This role partners with pharmacy, nursing, medical, quality, risk, and operational leaders to identify performance gaps, develop and implement improvement strategies, standardize workflows, and sustain measurable results related to quality, safety, regulatory readiness, throughput, operational reliability, and medication use outcomes.
The Manager is responsible for development, implementation, and ongoing evaluation of a system-wide medication safety and pharmacy performance improvement plan aligned with organizational priorities and applicable ACHC standards. The Manager applies structured performance improvement methods, including failure mode and effects analysis (FMEA), root cause analysis (RCA), medication safety event review, and AHRQ patient safety and systems-based improvement principles, along with project management, data analysis, and change management to drive results, monitor key metrics, and provide executive-ready updates to senior pharmacy leadership.
Baptist Health is looking for a Manager, Pharmacy Performance Improvement to join our team at the Central Pharmacy, LaGrange, KY!
Lead implementation of improvement plans that address pharmacy workflow efficiency, medication-use safety, compliance reliability, and service-line performance.
Operationalize the system-wide medication safety and pharmacy performance improvement plan by monitoring performance indicators, coordinating follow-up activities.
Develop and monitor outcome, process, and balancing measures to evaluate initiative effectiveness and identify opportunities for further optimization.
Support development of standard workflows, tools, education, and audit processes.
Analyze data trends, audit findings, and process performance.
Support standardization and optimization of pharmacy workflows related to dispensing, verification, medication distribution, inventory controls, formulary management, and medication use technology.
Monitor performance of pharmacy operational and safety indicators such as medication turnaround time, controlled substance discrepancies, override trends, expired medication reduction, diversion prevention controls, and medication storage compliance.
Oversee follow-up on identified improvement opportunities.
Coach leaders, pharmacists, and team members on performance improvement tools, structured problem solving, standardization, and sustainment practices.
Support governance structures by preparing updates, recommendations, and performance summaries for pharmacy and organizational leadership.
Provide leadership, direction, and development for direct reports.
Lead system pharmacy performance improvement initiatives aligned with strategic priorities, regulatory expectations, and operational goals across hospitals, HOPDs, ASCs, and FSEDs.
Develop, implement, and maintain a system-wide medication safety and pharmacy performance improvement plan.
Partner with pharmacy leadership and key stakeholders to identify performance gaps, define improvement opportunities, establish aims, and prioritize projects based on organizational impact and risk.
Develop improvement roadmaps, charters, and implementation plans to advance pharmacy quality, medication safety, regulatory readiness, operational reliability, and service performance.
Facilitate cross-functional teams and stakeholder discussions to support problem solving, remove barriers, and maintain accountability for deliverables and outcomes.
Use structured improvement methods such as Lean, PDSA, root cause analysis, failure mode and effects analysis, process mapping, standard work, and AHRQ-informed patient safety principles to support effective design and execution of improvement efforts.
Lead or support analysis of medication safety events, near misses, and system vulnerabilities.
Drive pharmacy-specific process improvement related to medication-use systems, including formulary standardization, automated dispensing cabinet optimization, controlled substance diversion prevention controls, inventory management, and transitions of care workflows.
Support improvement of sterile compounding, hazardous drug handling, medication preparation and dispensing workflows, barcode medication use processes, and medication storage practices.
Track project milestones, risks, and outcomes and communicate progress through executive-ready summaries, dashboards, and leadership updates.
Minimum Requirements
Bachelor's degree in pharmacy or Doctorate of Pharmacy required.
Master’s degree in Healthcare Administration, Business, Public Health, Quality, or related field preferred.
Minimum of 5 years of job-related experience required.
Kentucky Board of Pharmacy license in good standing.
Indiana Board of Pharmacy license or willing and eligible within 1 year of hire.
1-3 years related experience in pharmacy compliance or risk management.
Knowledge of state and federal pharmacy laws and regulations.
Preferred Qualifications
Experience leading healthcare performance improvement, quality, medication safety, or operational excellence initiatives.
Experience applying Lean, PDSA, root cause analysis, failure mode and effects analysis, process mapping, standard work, or similar structured improvement methodologies.
Experience with medication safety event review, event trend analysis, near miss evaluation, and development of risk reduction strategies.
Knowledge of AHRQ patient safety principles, systems-based analysis, and high-reliability approaches.
Experience with pharmacy-specific performance improvement work related to formulary management, automated dispensing cabinet optimization, controlled substance monitoring, diversion prevention, medication storage compliance, sterile compounding, hazardous drug handling, and transitions of care.
Experience with accreditation and regulatory standards, including Joint Commission, ACHC, USP standards, Board of Pharmacy requirements, or other applicable healthcare requirements.
Strong communication, facilitation, project management, and data analysis skills, including proficiency with Microsoft Excel, Word, PowerPoint, and other pharmacy-related applications.
Founded in 1924 in Louisville, Kentucky, Baptist Health is a full-spectrum health system dedicated to improving the health of the communities it serves. The Baptist Health family consists of nine hospitals, employed and independent physicians, and more than 400 points of care, including outpatient facilities, physician practices and services, urgent care clinics, outpatient diagnostic and surgery centers, home care, fitness centers, and occupational medicine and physical therapy clinics.
Baptist Health’s eight owned hospitals include more than 2,300 licensed beds in Corbin, Elizabethtown, La Grange, Lexington, Louisville, Paducah, Richmond and New Albany, Indiana. Baptist Health also operates the 410-bed Baptist Health Deaconess Madisonville in Madisonville, Kentucky in a joint venture with Deaconess Health System based in Evansville, Indiana. Baptist Health employs more than 23,000 people in Kentucky and surrounding states.
Baptist Health is the first health system in the U.S. to have all of its hospitals recognized by the American Nursing Credentialing Center with either a Magnet® or Pathway to Excellence® designation for nursing excellence.
Baptist Health’s employed provider network, Baptist Health Medical Group, has nearly 1,500 providers, including more than 750 physicians and more than 740 advanced practice clinicians. Baptist Health’s physician network also includes more than 2,000 independent physicians.
Learn more at BaptistHealth.com.
