What are the responsibilities and job description for the DIRECTOR - PERFORMANCE IMPROVEMENT position at West Oaks Hospital?
Performance Improvement Director OpportunityWest Oaks Hospital has provided psychiatric care to the Houston area and surrounding communities for over four decades. Our 176-bed acute care facility is fully accredited and includes a 16-bed residential treatment center for adult chemical dependency.We offer a broad range of behavioral health programs for children, adolescents, and adults. Treatment is offered at multiple levels of care including inpatient, partial hospitalization, and intensive outpatient.West Oaks Hospital is seeking a dynamic and talented Director, Performance Improvement to join our team of compassionate, dedicated professionals. The Director of Performance Improvement (DPI) has broad responsibility to ensure the hospital’s compliance at all times with all Joint Commission, CMS, TDSHS, and other regulatory agencies standards and requirements. The DPI is responsible for staff training and education on the hospital’s performance initiatives and measures including outcomes measurement and reporting.Job Duties / Responsibilities : Lead regulatory compliance with Joint Commission, CMS, DHHS, and other applicable agencies.Monitor PI indicators and action plans.Coordinate, review, and update hospital Performance Improvement Plans annually.Lead Performance Improvement Council monthly meetings. Prepare agenda; comply and present aggregate data and statistical reports; and take minutes.Submit and present quarterly PI report to Board of Directors.Lead and coordinate PI initiatives and activities, to include survey readiness.Ensure the hospital meets Joint Commission, CMS, and state regulatory requirements.Develop and implement a Performance Improvement Plan, evaluate the results monthly, and report the results to PI Committee, MEC, and BOG.Ensure that all deficiencies identified through the Performance Improvement analysis are addressed with appropriate problem-solving actions.Analyze statistical data of the hospital to determine and respond to trends.Consult with senior staff and directors in the development of department-specific programs and quality measures which are within the standards of Joint Commission, CMS, TDSHS, OSHA regulations, and all other applicable federal, state, or local law / regulations governing health-care entities.Prepares and submits monthly PI data to UHS by the 10th of each month or when required.Maintain and monitor Joint Commission website, coordinate all regulatory site visits, prepares and submits Corrective Action Plans in a timely manner.Qualifications Requirements : Bachelor’s Degree in related field. Preferred Master’s degree in Nursing.Four (4) years of professional experience in performance improvement and / or quality management / improving organizational performance within an acute medical or psychiatric treatment setting.Experience may be substituted with education on a 1 : 1 basis.CPR and de-escalation certification.RN License, Required.EEO StatementAll UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion, and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status, or any other characteristic protected by federal, state, or local laws.#J-18808-Ljbffr
