DIRECTOR - PERFORMANCE IMPROVEMENT

UHS•Jeffersonville, IN

3h•Onsite

About The Position

Wellstone Regional Hospital is a 100-bed acute care facility located in Jeffersonville, Indiana and has been providing quality health care to the residents of Southern Indiana and the Louisville area since 2003. Wellstone specializes in the treatment of Adolescents, Children, and the Adult population. In addition to our in-patient services, we offer out-patient programs as well. Wellstone is currently searching for a Director of Performance Improvement. The Director of Performance Improvement is responsible for directing and monitoring the facility-wide quality improvement assessment and performance improvement programs, ensuring the facility’s programs are in compliance with all regulatory agencies, TJC, and state and federal agencies. In addition to PI this role will also complete B-tag audits in conjunction to senior leadership. The PI Director serves as back-up for the Risk/Regulatory Director when out on PTO/leave.

Requirements

Bachelor's Degree required
One (1) year of related experience
Knowledge of psychiatric patient care techniques with understanding of mental illness
CPI and CPR training within first ninety (30) days of employment.
Knowledge of TJC, DMHA, OIG and all federal and state laws/regulations.
Demonstration of skills in problem-solving, critical thinking, written and verbal communication, interpersonal relationships.
Knowledge in team facilitation and ability to work as a team player.
Thorough knowledge of data collection, aggregation, statistical analysis, and use of statistical display tools.
Thorough knowledge of techniques, and methods of adult education.
Basic computer and mathematic skills.

Nice To Haves

Master's preferred in related field.
3 years preferred experience in psychiatric patient care techniques with understanding of mental illness.
Previous management/regulatory experience highly recommended.
Six Sigma Lean; Healthcare Quality Certification Board as CPHQ preferred.

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.
Maintain and monitor Joint Commission web site, coordinate all regulatory site visits, prepares and submits Corrective Action Plans in a timely manner.