Director of Performance Improvement and Compliance

Texoma Medical Center; Fort Washington (Montgomery County); On-site; USD 110,000 - 150,000; Full time

Job summary

Brooke Glen Behavioral Hospital, part of Universal Health Services, in Fort Washington, PA, seeks a Director of Performance Improvement and Compliance to lead hospital-wide PI activities and ensure regulatory alignment. The role collaborates with CEO, medical staff and committees to advance clinical outcomes and patient experience.

The position oversees data analytics, dashboard monitoring, staff training, and reporting to governing bodies, with accountability for maintaining compliance and

Qualifications

• Bachelor's degree in nursing, social work or related behavioral health field preferred or equivalent combination of education and experience.
• Minimum of four (4) years' experience in quality management/improving organizational performance within an acute psychiatric treatment setting preferred.

Responsibilities

• Develop, manage and coordinate hospital-wide Performance Improvement activities to improve clinical outcomes and patient experience.
• supervise PI activities daily and ensure timely action.
• Train staff in performance improvement and compliance program.
• Chair the hospital’s Quality Council and report to MEC and Governing Board.
• Develop methods to obtain required data/information.
• Maintain facility information on corporate UHS Clinical Services Performance Manager.
• Ensure monthly PI Indicator Entry is completed timely.
• Monitor PI Dashboard scores against benchmarks.
• Oversee patient satisfaction survey completion.
• Utilize reports from corporate Performance Manager for site reporting.
• Review department performance measures and coordinate reports of findings to committees.
• Advise all departments on performance improvement activities.
• Aggregate and analyze data from internal and external sources.
• Report PI data and action plans to Governing Board and Senior Managers.
• Participate in committee meetings where PI activities occur.

Skills

Leadership

Quality management

Data analysis

Regulatory compliance

Staff training

Report writing

Education

Bachelor's degree in nursing or related behavioral health field

Job description

Responsibilities

Brooke Glen Behavioral Hospital has been providing psychiatric services to the Philadelphia area for more than 40-years. Located in Fort Washington, PA, our 146-bed facility provides a peaceful setting for those seeking treatment for mental illness. Brooke Glen offers unique and individualized programming for adolescents and adults that sets us apart from many other treatment facilities, and our tenured leadership team includes a seasoned nursing department.

Website: https://www.brookeglenhospital.com/

The Director of Performance Improvement and Compliance is a Full-Time position, supporting the CEO in the development and implementation of the mission, goals and objectives of the facility as established by the governing body. The Director of Performance Improvement and Compliance assist the leadership, medical staff and PI Committee in designing, planning, implementing and overseeing a comprehensive and integrated performance improvement program. This role ensures compliance with hospital, accreditation, federal, state, local and other regulatory agency standards. Provides day-to-day operational oversight for ancillary or assigned departments. Implement strategy of CEO. Handles sensitive and confidential materials.

Qualifications

QUALIFICATIONS:

Education: Bachelor’s Degree from an accredited college or university in nursing, social work or related behavioral health field preferred or equivalent combination of education and experiene.

Experience: Minimum of four (4) years' experience in quality management/improving organizational performance within an acute psychiatric treatment setting preferred.

JOB RESPONSIBILITIES

• Accountable for the development, management and coordination of hospital-wide Performance Improvement activities designed to advance clinical outcomes and patient experience.
• Supervising and supporting PI activities on a daily basis and assuring that action is taken as needed.
• Train staff in performance improvement and compliance program.
• Chair the hospital’s Quality Council and provide report to Medical Executive Committee and Governing Board.
• Developing appropriate methods for obtaining required data/information.
• Maintaining facility information on corporate UHS Clinical Services Performance Manager.
• Ensure monthly PI Indicator Entry is completed timely.
• Monitor PI Dashboard scores against benchmarks.
• Oversee patient satisfaction survey completion
• Utilize data/reports including those from corporate Performance Manager site for reporting to facility committees and PI Teams
• Receive/review department performance measures and documentation and coordinate reports of findings to Quality Council, MEC and Governing Body.
• Advise/assist all departments and committees accountable for performance improvement activities
• Aggregate and analyze data from both internal and external sources
• Report PI data, survey outcomes, corrective action plan status to the Governing Board, Medical Executive Committee, and Senior Managers
• Participate in appropriate committee meetings in which PI activities occur and share data with appropriate committees.
• Ensure the hospital is meeting regulatory expectations with program policies.
• Performs other duties as assigned/required by this position.

What do our current staff value at Brooke Glen BH & UHS?

A safe and supportive environment that puts patient care first and values the nursing profession. One of the most rewarding aspects of working as a staff member at Brooke Glen is providing excellent care, comfort, and security to the patients and families you treat, at their most vulnerable times. You are never alone, as you are part of a large, nationwide network of peers and leaders that educate the field, routinely exchange ideas, and review current topics within the industry. At UHS, you have a voice.

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success.