Director of Performance Improvement

Texoma Medical Center; Forest Park (IL); On-site; USD 90,000 - 120,000; Full time

Job summary

Riveredge Hospital in Forest Park, IL, part of Universal Health Services, seeks an experienced manager to lead quality improvement and performance initiatives in behavioral health care. The role emphasizes clinical excellence, patient safety, regulatory compliance, and multidisciplinary collaboration to advance mission and outcomes.

You will supervise PI teams, drive data-informed decision making, conduct staff education, and ensure adherence to Joint Commission, CMS and OSHA standards across

Qualifications

• Minimum 4 years of management experience in hospital-based behavioral care.
• Illinois Licensed Professional Nurse.
• Bachelor’s degree or Masters-prepared clinician in psychology or related field.
• Expert knowledge of Joint Commission standards, CMS, OSHA regulations and other regulatory standards.

Responsibilities

• Evaluate and interpret policy and procedure to improve clinical practice and service.
• Lead performance improvement initiatives and track data to ensure quality care and regulatory compliance.
• Manage PI teams, conduct regular PI meetings, and collaborate with department heads on improvement plans.
• Education programs: provide staff training on quality improvement and regulatory standards.
• Supervise PI associates to align work with organizational priorities and ensure compliance.

Skills

Quality improvement

Data analysis

Regulatory compliance

Leadership

Education

Illinois Licensed Professional Nurse

Bachelor’s degree or Masters-prepared clinician in psychology or related field

Job description

Responsibilities

Shape the future of behavioral health care throughout the Forest Park community by joining our extraordinary team at Riveredge Hospital. Bring your compassion, expertise, enthusiasm, and passion for quality to a place that cultivates wellness and inspires hope.

EVALUATES THE QUALITY AND EFFECTIVENESS OF CLINICAL PRACTICES AND SERVICE ADMINISTRATION

1. Understands and interprets policy and procedure.
2. Identifies problems and issues related to quality and proposes courses of action to resolve issues
3. Establishes standards with which to measure the effectiveness of clinical practice and service.
4. Assures processes are in place to collect and maintain pertinent data in the organization.
5. Participates in the decision-making structure with other hospital leaders to develop REH mission, strategic plans and policy.
6. Conduct rounds and perform risk analysis .

PERFORMANCE IMPROVEMENT

1. Tracks, trends, and shares data to ensure compliance with quality care standards, internal and external regulatory requirements, and patient centered care.
2. Benchmarks best practices through external survey, data analysis and strategic planning initiatives.
3. Identifies opportunities for service and clinical improvement
4. Leads unit/organizational performance improvement initiatives including identification of indicators based on identified trends, review, and analysis of data,
5. Trends patient and referral source satisfaction and complaints contributing to action plans, implementation and evaluation.
6. Maintains survey readiness at all times

MANAGEMENT OF P.I. TEAMS

1. Collaborate with clinical staff at all levels , multi-disciplinary teams, senior managers and other stakeholders in the development and implementation of P.I. teams.
2. Leads regular P.I. meetings and steers individual PI teams, communicating information critical to unit functioning, safety and patient focused care.
3. Participates in team building and conflict resolution in order to ensure hospital, unit and patient goals are accomplished according to identified standards of care and compliance with internal and external regulatory bodies.
4. Maintains and shares updated knowledge related to mental health legislation, patient rights, discharge process, interventions, annual training in Protective Intervention and CPR and eligibility criteria for services at Riveredge Hospital.
5. Interfaces with all department heads and guides them in performance improvement initiatives.

CONDUCT EDUCATION PROGRAMS

1. Instruct staff in the use of standardized formats to create universally understood quality improvement and reporting tools.
2. Provides educational support to all REH departments with regard to performance improvement, accreditation standards and other regulatory standards.
3. Contributes to clinical management education and professional development of staff, students and colleagues.
4. Fosters an understanding of the effective use of organization, management, and clinical theories and research.

MANAGE P.I. ASSOCIATE

1. Assure work processes are aligned with organizational needs and priorities
2. Monitor and evaluate work; provide supervision to assure developmental opportunities are met
3. Maintain compliance with all REH polices and practices.

Qualifications

EDUCATION

• Illinois Licensed Professional Nurse, with a minimum Bachelor Degree orMasters-prepared clinician in psychology or related field.
• A minimum of 4 years of management experience, preferably in a Hospital based behavioral care.
• Has expert knowledge of Joint Commission standards, CMS, OSHA regulations and all other relevant state and federal regulatory standards.