Responsibilities
Wellstone Regional Hospital is a 100-bed acute-care facility located in Jeffersonville, Indiana, providing quality health care to the residents of Southern Indiana and the Louisville area. The hospital specializes in treatment of adolescents, children, and the adult population, offering both in-patient and out-patient programs. We are seeking a Director of Performance Improvement.
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, including 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 that meet standards of Joint Commission, CMS, TDSHS, OSHA regulations and all applicable federal, state or local laws.
- Prepare and submit monthly PI data to UHS.
- Maintain and monitor Joint Commission website, coordinate all regulatory site visits, prepare and submit Corrective Action Plans in a timely manner.
Benefits
- 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
Education: Bachelor’s Degree required; Master’s preferred in related field.
Experience: One year of related experience, with knowledge of psychiatric patient care techniques and understanding of mental illness; three years preferred. Previous management/regulatory experience highly recommended.
Licensure/Certifications: Six Sigma Lean; Healthcare Quality Certification Board as CPHQ preferred.
Additional Requirements: CPR training within first thirty 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 of 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 mathematical 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.
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