DIRECTOR - PERFORMANCE IMPROVEMENT

UHS•Raleigh, NC

About The Position

The Director of Performance Improvement (DPI) is responsible for coordinating and monitoring the facility-wide quality management assessment and quality performance improvement program, ensuring the facility’s programs are following all regulatory agencies, Joint Commission, CMS, and all other state and federal agencies. The DPI is responsible for staff training and education on the hospital’s performance initiatives and measures including outcomes measurement and reporting.

Requirements

Bachelor’s Degree from an accredited college or university in nursing, or related health field required.
Four (4) years of experience in quality and risk management/improving organizational performance within an acute medical or psychiatric treatment setting.
A strong knowledge of JOINT COMMISSION, TDSHS, CMS standards, and any other applicable federal and state laws and regulations governing mental health care facilities.
Knowledge of Joint Commission, NAPHS, HCFA, OSHA and patient rights standards, and all federal and state laws/regulations.
Knowledge of quality management principles, practices and techniques.
Knowledge of performance improvement planning techniques and goals.
Knowledge of computers and various software.
Strong analytical interpretation skills.
Skill in organizing and prioritizing workloads to meet deadlines.
Skill in telephone etiquette and paging procedures.
Effective oral and written communication skills.
Ability to communicate effectively with patients and co-workers.
Ability to adhere to safety policies and procedures.
Ability to use good judgement and to maintain confidentiality of information.
Ability to work as a team player.
Ability to demonstrate tact, resourcefulness, patience and dedication.
Ability to accept direction and adhere to policies and procedures.
Ability to recognize the importance of adapting to the various patient age groups (adolescent, adult and geriatric).
Ability to work in a fast-paced environment.
Ability to meet corporate deadlines.
Ability to react calmly and effectively in emergency situations.
Ability to supervise personnel.
Ability to work at least 40 hours per week, and flexible hours and overtime as required.
Ability to sit for long periods, up to 8 hours.
Ability to use both hands in fine and gross manipulation of small tools (copier, computer, telephone, typewriter, calculator, safe, facsimile machine).
Ability to push and pull up to 10 lbs. (file cabinet drawers, computer paper boxes).
Ability to communicate clearly and see well enough to read handwritten and typewritten material.
Ability to lift and carry up to 25 lbs. dead weight.
Ability to stoop, kneel and bend daily.
Ability to reach, turn, and twist above and below the waist daily.
Ability to stand and walk on the facility grounds daily.
Ability to spend 10% of working time outside in temperatures varying from 30° F. to 105° F.
Ability to spend 90% of working time in an environment of continuous low voices and office machine noise typical of business office atmosphere.
Ability to handle a variety of repetitive tasks at a moderate level.

Nice To Haves

Master’s Degree preferred.

Responsibilities

Provide a broad vision in the continuous development and direction of quality management and quality improvement programs for the facility.
Provide direction and consultation to all staff members on the concepts of Total Quality Management (TQM) and the use of total quality management tools in the application to patient care.
Consult with senior staff and directors in the development of department specific programs and quality measures which are within the standards of Joint Commission, TDH, CMS, TCADA, OSHA regulations and all other applicable federal, state or local law/regulations governing health-care entities.
Develop a facility-wide performance improvement plan which meets or exceeds all regulatory standards and develop performance measurement indicators.
Provide continuous support in the analysis of performance improvement goals and objectives, re-establishing requirements which will facilitate continuous improvement.
Review the results of performance improvement requirements with each department director, define performance improvement requirements for the department and involve other departments/services in the problem-solving process when situations span over more than one department.
Establish a system for collecting and analyzing statistical data relating to performance improvement measures.
Ensure any detected deficiency in meeting quality improvement goals and objectives is addressed with appropriate management in a timely manner.
Assist the medical staff in compiling physician’s/licensed practitioners IOP Profiles, which will be used in the medical staff reappointment process.
Provide consultation to the medical staff in carrying out all the medical staff reporting functions (i.e. drug usage, evaluation, pharmacy, and therapeutics, infection control, utilization review, quality improvement, safety and risk management and medical records review).
Prepare annual IOP appraisals.
Participate in quality improvement meetings on a regular basis to develop and continuously encourage a facility-wide team effort in meeting quality improvement efforts.
Manage performance improvement data and information flow, as outlined in the IOP Plan.
Assist as needed with collection of the incident report process.
Maintain a performance improvement record for all contract service providers.
Develop and maintain a record on performance improvement activities and all committee minutes associated with quality programs.
Assist with activities related to the Patient Advocate function.
Consult with Risk Management and other Senior Team Leaders related to possible risks as relating to hospital/patient safety as needed and/or as identified in PI data/reports.
Support the Chief Executive Officer in preparing and presenting the results of facility performance improvement activities, as well as the functioning of all Medical Staff committees to the Consulting Board on a quarterly basis.
Provide services to current referral sources to assure their satisfaction and continued associations.
Ensure the implementation of an ongoing system of program orientation for patients, families and professionals and others.
Provide educational and professional development.
Ensure programs adhere to specific Standards of Care of Child Patients ages 5 through 11.
Ensure programs adhere to specific Standards of Care of Adolescent Patients ages 12 through 18.
Ensure programs adhere to specific Standards of Care of Adult Patients ages 19 through 64.
Ensure programs adhere to specific Standards of Care of Geriatric Patients ages 65 and older.
Adhere to facility, department, corporate, personnel and standard policies and procedures.
Attend all mandatory facility in-services and staff development activities as scheduled.
Adhere to facility standards concerning conduct, dress, attendance and punctuality.
Support facility-wide quality/performance improvement goals and objectives.
Maintain confidentiality of facility employees and patient information.
Adhere to Service Excellence Standards and serve as role models to others.