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DIRECTOR - PERFORMANCE IMPROVEMENT (RN License required)

Universal Hospital Services Inc., Houston, TX, United States


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 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 within the standards of Joint Commission, CMS, TDSHS, OSHA regulations and all other applicable federal, state or local law/regulations governing health‑care entities.

Prepare and submit monthly PI data to UHS by the 10th of each month or when required.

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

Benefits

Loan Forgiveness Program

Relocation Bonus as needed

Challenging and rewarding work environment

Competitive Compensation & Generous Paid Time Off

Excellent Medical, Dental, Vision and Prescription Drug Plans

401(K) with company match and discounted stock plan

SoFi Student Loan Refinancing Program

Career development opportunities within UHS and its 300+ Subsidiaries!

Qualifications

Bachelor’s Degree in related field. Preferred Master’s degree in Nursing.

Four (4) years of professional experience in performance improvement and/or quality management/improving organizational performance within an acute medical or psychiatric treatment setting.

Experience may be substituted with education on a 1:1 basis.

CPR and de‑escalation certification.

RN License, Required.

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.

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