DIR - PERFORMANCE IMPROVEMENT

UHS•San Antonio, TX

109d

About The Position

The Director of Performance Improvement directs the process of establishing a comprehensive and integrated performance improvement program which meets regulatory standards for the hospital, partial hospitalization, and outpatient programs. The Director of Performance Improvement strives to emphasize an organization-wide approach in regards to continually meeting and/or exceeding licensing and accreditation standards, in order to deliver quality care and cost – effective treatment. The Director leads and assists with responses to potential quality of care issues; evaluates the effectiveness of measurements and analysis of data throughout the facility; oversees regulatory compliance and provides corrective action plans to licensing agencies, regulatory and accreditation bodies and to external reviewers with contracts for services; coordinates with the CEO and Executive Medical Director to insure a proactive approach to quality care and improving performance throughout the facility.

Requirements

Education: Bachelor's Degree required, Masters Degree preferred.
Related work experience: 5 to 8 years
Licensure/Certification/Registration: RN, LPC or LMSW preferred
Quality Professional Certificate preferred

Responsibilities

Strategic Planning: Provide a broad vision in the strategic development and direction of the performance improvement program for the hospital. Develop and implement a comprehensive performance improvement strategy that aligns with the organization’s goals and objectives. Develop a facility-wide performance improvement plan which meets regulatory standards.
Data Analysis & Reporting: Establish a system for collecting and analyzing data related to performance improvement measures for both the inpatient hospital program and the outpatient behavioral health program. Consult with senior staff and directors in the development and analysis of department performance improvement quality measures. Maintain a list of hospital-wide performance improvement indicators which includes monthly and quarterly data, and prepare graphs of performance trends to drill down on issues needing action.
Process Improvement & Change Management: Identify opportunities for process optimization and operational efficiencies across the organization. Lead initiatives to streamline workflows, reduce waste, and improve service delivery. Analyze performance metrics and key performance indicators (KPIs) to identify trends, issues, and opportunities for improvement. Prepare and present reports on performance improvement progress to senior management and stakeholders. Develop and implement change management strategies to ensure smooth adoption of performance improvement initiatives. Address resistance to change and build consensus around new processes and practices.
Compliance & Standards: Ensure the hospital is continuously survey ready with systems in place for monitoring. Assists the Senior Management Team of the Facility in making critical decisions by providing guidance on licensing, regulatory and accreditation requirements. Lead compliance efforts and route licensing and accreditation standards to leaders and managers as indicated. Responds to potential quality of care issues and prepares Management Team for announced and unannounced surveys and reviews.
Collaboration and Communication: Provide training to staff members on the concepts of performance improvement and the application to patient care via orientation of all new hires, and staff training and participation in PI initiatives. Provide compliance consultation to managers through scheduled Performance Improvement Committee meetings, Senior Staff meetings, and Compliance meetings. Work closely with department heads and teams to understand their needs and provide support.
Patient Satisfaction: Tabulate staff, patient, referral source, and / or physician satisfaction surveys. Lead improvement efforts of satisfaction survey outcomes.
Project Management: Participate in the facility Environmental Safety tour/walk-through inspections. Compile reports of actual/potential improvement opportunities identified inthe environment of care. Oversee the planning, execution, and evaluation of proactive performance improvement and continuous quality improvement (CQI) projects to proactively improve quality of care. Manage project timelines, resources, and budgets to ensure successful project outcomes. Conduct proactive risk assessment of a high risk process completed to address safety concerns.
Team Leadership: Chair PI Committee Meetings 10 to 12 times yearly. Develop and maintain a record on performance improvement activities and keep PI Committee minutes in an accessible binder. Oversight of HBIPS core measure collection, entry, and performance. Foster a culture of continuous improvement and professional development within the team.
Reporting: Ensure timely reporting of all Peer Review reports, assigns classification level and communicates those reports with a severe classification through the appropriate channels. Facilitate the OPPE/FPPE process
Innovation: Stay updated on industry trends and best practices in performance improvement. Introduce innovative approaches and technologies to drive organizational growth