DIRECTOR - PERFORMANCE IMPROVEMENT

Universal Health Services; Jeffersonville (IN); On-site; USD 120,000 - 170,000; Full time

Benefits offered by this job

Challenging environment

Growth opportunities within UHS and 充

Competitive pay

401k with company match

Paid time off

Tuition reimbursement

Service excellence culture

Free meals

Pet insurance

Job summary

Wellstone Regional Hospital, a 100-bed acute care facility in Jeffersonville, IN, is seeking a Director of Performance Improvement to lead hospital-wide quality improvement and regulatory compliance initiatives. The role includes back-up for the Risk/Regulatory Director and B-tag audits in collaboration with senior leadership.

Responsibilities cover Joint Commission, CMS, and state compliance, PI indicator monitoring, annual PI plan updates, and monthly PI Council activities with data-driven

Qualifications

• Education: Bachelor's Degree required; Master's preferred.
• Experience: 1 year in related field; 3 years preferred with management/regulatory exposure.
• Licensure/Certifications: Six Sigma Lean; CPHQ preferred.
• Additional Requirements: CPI and CPR training within 90 days of employment; flexible hours may be required.
• Hours: Primarily day shift; other times as indicated by supervisor.

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 PI Council monthly meetings; prepare agenda; present data; take minutes.
• Submit and present quarterly PI report to Board of Directors.
• Lead and coordinate PI initiatives and activities, including survey readiness.
• Ensure compliance with Joint Commission, CMS, and state requirements.
• Develop and implement a PI Plan; evaluate results monthly and report to PI Committee, MEC and BOG.
• Ensure deficiencies identified are addressed with problem-solving actions.
• Analyze hospital data to determine trends and respond accordingly.
• Consult with senior staff to develop department programs and quality measures.

Skills

Regulatory compliance

Data analysis

Project management

Team leadership

Communication

Problem solving

Adult education

CPI/CPR training readiness

Education

Bachelor's degree

Master's degree (preferred)

Tools

Statistical display tools

Six Sigma Lean (cert)

Job description

Responsibilities

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.

https://www.wellstonehospital.com.

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.

Job Duties/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.

This opportunity provides the following:

• UHS is Challenging and rewarding work environment
• Growth and development opportunities within UHS and its 400+ subsidiaries
• Competitive Compensation
• 401k plan with company match
• Generous Paid Time Off
• Tuition Reimbursement
• Service Excellence atmosphere!
• Free Meals!!!!
• Pet Insurance

Qualifications

About UHS

Headquartered in King of Prussia, PA, Universal Health Services, Inc. (NYSE: UHS) is one of the nation's largest and most respected providers of hospital and healthcare services. Since our founding in 1979, UHS has grown steadily into a premier Fortune 500 corporation perennially recognized by multiple esteemed national rating entities. Through its subsidiaries, UHS operates inpatient acute care facilities, inpatient behavioral health facilities, outpatient and other facilities, nationwide virtual behavioral health services, an insurance offering, a physician network and various related services with physical locations in the U.S., Puerto Rico, Ireland and United Kingdom. www.uhs.com.

For more information about this position please contact HR Dir., Tiffany Pierce, [e-mail].

QUALIFICATIONS

Education: Bachelor's Degree required, Master's preferred in related field.

Experience: One (1) year of related experience, with knowledge of psychiatric patient care techniques with understanding of mental illness, 3 years preferred. Previous management/regulatory experience highly recommended.

Licensure/Certifications: Six Sigma Lean; Healthcare Quality Certification Board as CPHQ preferred.

Additional Requirements: CPI and CPR training within first ninety (30) days of employment. May be required to work flexible hours when needed.

Hours of Work: Primarily day shift, other times as indicated by immediate supervisor.

Knowledge and Skills:

• 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.

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.