DIR - PERFORMANCE IMPROVEMENT

UHS•Lewisville, TX

4d•Onsite

About The Position

Horizon Health Corporation is seeking a Director of Performance Improvement. The Director of Performance Improvement is responsible for the development, implementation, monitoring, and analysis of performance improvement projects and activities with a focus on improving patient safety and quality of care. The Director of Performance Improvement sets priorities for improvements aligned to ongoing strategic initiatives. Leads and directs process improvement activities that provide a more efficient and streamlined workflow in the hospital. The Director of Performance Improvement is responsible for coordinating an organization–wide approach to continual compliance with all appropriate regulatory and licensing standards. Is responsible for assessing potential risk to the program and reporting incidents/concerns to the Director of Risk in partner facilities. Other risk-related job duties will be assigned as needed. One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune 500 corporation, annual revenues were $14.3 billion in 2023. During 2024, UHS was again recognized as one of the World’s Most Admired Companies by Fortune; and in 2023, listed in Forbes ranking of America’s Largest Public Companies. Headquartered in King of Prussia, PA, UHS has approximately 96,700 employees and continues to grow through its subsidiaries. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com

Requirements

Bachelor’s degree in nursing, social work, mental health/behavioral sciences or related field required
Minimum of 5–7 years of progressive experience in healthcare quality improvement, performance improvement, or operations management required.
Demonstrated experience managing quality metrics, regulatory compliance, and cross-functional improvement initiatives.
Proven ability to analyze data, develop action plans, and drive measurable outcomes.
Strong leadership and team collaboration skills
Excellent analytical and problem-solving abilities
Ability to manage multiple priorities in a fast-paced environment
Knowledgeable regarding Joint Commission accreditation standards.
Strong project management and organizational skills
Effective communication and facilitation skills
Working knowledge of behavioral health regulations and compliance standards
Change management and resilience-building in high-acuity settings
Ability to influence others and drive change across multiple sites
High attention to detail and commitment to quality and patient safety

Nice To Haves

Relevant certifications in quality improvement, performance improvement, Lean, Six Sigma, or similar methodologies preferred.
Minimum of 5 years of progressive experience directing performance improvement and risk management activities in a hospital, psychiatric hospital, or mental health treatment setting preferred.
Experience in behavioral health, inpatient psychiatric care, crisis services, or emergency behavioral health settings strongly preferred.
Experience leading multi-site or multi-unit operations preferred.
Experience interpreting State and Federal standards related to hospital operations preferred.
Experience with accreditation and regulatory standards applicable to behavioral health services preferred.

Responsibilities

Provide a broad vision in the strategic development and direction of the performance improvement program for the hospital.
Develop a facility-wide performance improvement plan which meets regulatory standards.
Provide training to staff members on the concepts of performance improvement and the application to patient care via orientation of all new hires.
Provide compliance consultation to managers through scheduled Performance Improvement Committee meetings, Department Manager meetings, and Compliance meetings.
Provide updates and training on licensing and accreditation standards to leaders and managers as indicated.
Establish a system for collecting and analyzing data related to QA/PI measures organization wide.
Consult with Senior Management and Directors in the development of department performance improvement quality measures.
Maintain a list of hospital-wide improvement indicators which includes monthly and quarterly data.
Participate in Root Cause Analyses and Failure modes and effects analyses and debriefings.
Oversee reporting and communication of quality improvement initiatives, quality and patient safety awareness, safety culture survey administration and patient satisfaction.
Promote a culture of safety, high reliability, patient and staff engagement, and performance excellence.
Oversee regulatory readiness and assists with preparing for Joint Commission, state licensing, CMS or other agencies.
Maintain Joint Commission contact information and application.
Coordinate and submit annual Joint Commission Application updates.
Establishes quality improvement activities and methods to track implementation of action plans following site surveys.
Ensure that the facility is in compliance with all Quality Measures and completes monthly auditing/reporting.
Monitor and report on results and address any areas needing improvement.
Submit monthly indicator information for the Clinical Services Dashboard.
Review, analyze and maintain quality dashboards and performance metrics.
Coordinates monthly record audit process, compile reports and presents data/analysis to Hospital Committees.
Develop appropriate action plans to improve compliance issues.
Coordinate the PI Committee/Quality Council by serving as the administrator.
Convenes regular monthly meetings, sets agendas, develops and analyzes performance improvement data for the council, designs and implements the necessary Quality Council processes and systems.
Develop and maintain a record on performance improvement activities and maintain PI Committee minutes and reports.
Prepare and present the results of hospital-wide performance improvement activities to the Medical Staff.
Prepare and present the results of hospital-wide performance improvement activities to the Governing Body each quarter.
Perform other duties as assigned/required by this position.