Director of Performance Improvement and Compliance

UHS•Whitemarsh Township, PA

About The Position

Brooke Glen Behavioral Hospital is a 146-bed psychiatric facility in Fort Washington, Pennsylvania, providing individualized programming for adolescents and adults. The Director of Performance Improvement and Compliance is a full-time role supporting the CEO in developing and implementing the facility’s mission, goals, and objectives as established by the governing body. The director works with hospital leadership, medical staff, and the Performance Improvement (PI) Committee to design, plan, implement, and oversee a comprehensive, integrated performance improvement program. The role ensures compliance with hospital, accreditation, and applicable federal, state, local, and other regulatory standards, provides day-to-day operational oversight for ancillary or assigned departments, implements the CEO’s strategy, and handles sensitive and confidential materials.

Requirements

Minimum of four years of experience in quality management or improving organizational performance within an acute psychiatric treatment setting is preferred.
Bachelor’s degree from an accredited college or university in nursing, social work, or a related behavioral health field is preferred, or an equivalent combination of education and experience.

Nice To Haves

Bachelor’s degree in nursing, social work, or a related behavioral health field.
At least four years of quality management or organizational performance improvement experience in an acute psychiatric treatment setting.

Responsibilities

Develop, manage, and coordinate hospital-wide Performance Improvement activities aimed at advancing clinical outcomes and patient experience.
Supervise and support daily PI activities and ensure action is taken as needed.
Train staff in performance improvement and the compliance program.
Chair the hospital’s Quality Council and report to the Medical Executive Committee and Governing Board.
Develop appropriate methods for obtaining required data and information.
Maintain facility information on the corporate UHS Clinical Services Performance Manager.
Ensure monthly PI Indicator Entry is completed on time.
Monitor PI Dashboard scores against benchmarks.
Oversee completion of patient satisfaction surveys.
Use data and reports, including those from the corporate Performance Manager site, for reporting to facility committees and PI Teams.
Receive and review department performance measures and documentation, and coordinate reports of findings to the Quality Council, Medical Executive Committee, and Governing Body.
Advise and assist departments and committees responsible for performance improvement activities.
Aggregate and analyze data from internal and external sources.
Report PI data, survey outcomes, and corrective action plan status to the Governing Board, Medical Executive Committee, and Senior Managers.
Participate in appropriate committee meetings where PI activities occur and share data with relevant committees.
Ensure hospital program policies meet regulatory expectations.
Provide day-to-day operational oversight for ancillary or assigned departments and implement the CEO’s strategy.
Perform other duties as assigned or required by the position.
Handle sensitive and confidential materials.