Head of Performance Improvement & Regulatory Compliance

Universal Health Services; Washington (Washington County); On-site; USD 110,000 - 170,000; Full time

Job summary

Brooke Glen Behavioral Hospital in Fort Washington, PA, part of Universal Health Services, seeks a Director of Performance Improvement and Compliance to lead the hospital-wide PI program and ensure regulatory standards are met. The role reports to the CEO and collaborates with medical staff and PI committees to optimize patient outcomes and experience.

The ideal candidate will have a nursing or behavioral health background and at least four years of experience in quality improvement within an

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

• Accountable for 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 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.

Education

Bachelor’s Degree in nursing, social work or related behavioral health field

Job description

Brooke Glen Behavioral Hospital in Fort Washington, PA, part of Universal Health Services, seeks a Director of Performance Improvement and Compliance to lead the hospital-wide PI program and ensure regulatory standards are met. The role reports to the CEO and collaborates with medical staff and PI committees to optimize patient outcomes and experience.

The ideal candidate will have a nursing or behavioral health background and at least four years of experience in quality improvement within an