DIRECTOR - PERFORMANCE IMPROVEMENT

About Universal Health Services

One of the nation's largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune 500 corporation, annual revenues were $15.8 billion in 2024. UHS was again recognized as one of the World's Most Admired Companies by Fortune; listed in Forbes ranking of America's Largest Public Companies. Headquartered in King of Prussia, PA, UHS has approximately 99,000 employees and continues to grow through its subsidiaries. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points,

an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com

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.

Notice

Avoid and Report Recruitment Scams

We are aware of a scam whereby imposters are posing as Recruiters from UHS, and our subsidiary hospitals and facilities. Beware of anyone requesting financial or personal information.

At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc.

If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.

POSITION SUMMARY

The Director of Performance Improvement (DPI) is responsible for coordinating and monitoring the facility-wide quality management assessment and quality performance improvement program, ensuring the facility's programs are following all regulatory agencies, Joint Commission, CMS, and all other state and federal agencies. The DPI is responsible for staff training and education on the hospital's performance initiatives and measures including outcomes measurement and reporting.

QUALIFICATIONS

Education: Bachelor's Degree from an accredited college or university in nursing, or related health field required. Master's Degree preferred.

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

Additional Requirements: A strong knowledge of JOINT COMMISSION, TDSHS, CMS standards, and any other applicable federal and state laws and regulations governing mental health care facilities.

STANDARDS OF PERFORMANCE

THE ESSENTIAL JOB FUNCTIONS ARE CATEGORIZED UNDER THE JCAHO STANDARDS OF PERFORMANCE.

Programming Planning

1. Provide a broad vision in the continuous development and direction of quality management and quality improvement programs for the facility.
2. Provide direction and consultation to all staff members on the concepts of Total Quality Management (TQM) and the use of total quality management tools in the application to patient care.
3. Consult with senior staff and directors in the development of department specific programs and quality measures which are within the standards of Joint Commission, TDH, CMS, TCADA, OSHA regulations and all other applicable federal, state or local law/regulations governing health-care entities.
4. Develop a facility-wide performance improvement plan which meets or exceeds all regulatory standards and develop performance measurement indicators.
5. Provide continuous support in the analysis of performance improvement goals and objectives, re-establishing requirements which will facilitate continuous improvement.
6. Review the results of performance improvement requirements with each department director, define performance improvement requirements for the department and involve other departments/services in the problem-solving process when situations span over more than one department.
7. Establish a system for collecting and analyzing statistical data relating to performance improvement measures.
8. Ensure any detected deficiency in meeting quality improvement goals and objectives is addressed with appropriate management in a timely manner.
9. Assist the medical staff in compiling physician's/licensed practitioners IOP Profiles, which will be used in the medical staff reappointment process.
10. Provide consultation to the medical staff in carrying out all the medical staff reporting functions (i.e. drug usage, evaluation, pharmacy, and therapeutics, infection control, utilization review, quality improvement, safety and risk management and medical records review).
11. Prepare annual IOP appraisals.
12. Participate in quality improvement meetings on a regular basis to develop and continuously encourage a facility-wide team effort in meeting quality improvement efforts.
13. Manage performance improvement data and information flow, as outlined in the IOP Plan.
14. Assist as needed with collection of the incident report process.
15. Maintain a performance improvement record for all contract service providers.
16. Develop and maintain a record on performance improvement activities and all committee minutes associated with quality programs.
17. Assist with activities related to the Patient Advocate function.
18. Consult with Risk Management and other Senior Team Leaders related to possible risks as relating to hospital/patient safety as needed and/or as identified in PI data/reports.
19. Support the Chief Executive Officer in preparing and presenting the results of facility performance improvement activities, as well as the functioning of all Medical Staff committees to the Consulting Board on a quarterly basis.

Professional Collaboration

1. Provide services to current referral sources to assure their satisfaction and continued associations.
2. Ensure the implementation of an ongoing system of program orientation for patients, families and professionals and others.
3. Provide educational and professional development.

Patient Care Standards

1. Ensure programs adhere to specific Standards of Care of Child Patients ages 5 through 11.
2. Ensure programs adhere to specific Standards of Care of Adolescent Patients ages 12 through 18.
3. Ensure programs adhere to specific Standards of Care of Adult Patients ages 19 through 64.
4. Ensure programs adhere to specific Standards of Care of Geriatric Patients ages 65 and older.

Additional Standards

1. Adhere to facility, department, corporate, personnel and standard policies and procedures.
2. Attend all mandatory facility in-services and staff development activities as scheduled.
3. Adhere to facility standards concerning conduct, dress, attendance and punctuality.
4. Support facility-wide quality/performance improvement goals and objectives.
5. Maintain confidentiality of facility employees and patient information.
6. Adhere to Service Excellence Standards and serve as role models to others.

Note: The essential job functions of this position are not limited to the duties listed above

KNOWLEDGE, SKILLS, AND ABILITIES

THIS SECTION DESCRIBES WHAT KNOWLEDGE, SKILLS AND ABILITIES AN EMPLOYEE IN THIS POSITION SHOULD CURRENTLY POSSESS. THIS LIST MAY NOT BE COMPLETE FOR ALL KNOWLEDGE, SKILLS AND ABILITIES REQUIRED FOR THIS POSITION.

1. Knowledge of Joint Commission, NAPHS, HCFA, OSHA and patient rights standards, and all federal and state laws/regulations.
2. Knowledge of quality management principles, practices and techniques.
3. Knowledge of performance improvement planning techniques and goals.
4. Knowledge of computers and various software.
5. Strong analytical interpretation skills.
6. Skill in organizing and prioritizing workloads to meet deadlines.
7. Skill in telephone etiquette and paging procedures.
8. Effective oral and written communication skills.
9. Ability to communicate effectively with patients and co-workers.
10. Ability to adhere to safety policies and procedures.
11. Ability to use good judgement and to maintain confidentiality of information.
12. Ability to work as a team player.
13. Ability to demonstrate tact, resourcefulness, patience and dedication.
14. Ability to accept direction and adhere to policies and procedures.
15. Ability to recognize the importance of adapting to the various patient age groups (adolescent, adult and geriatric).
16. Ability to work in a fast-paced environment.
17. Ability to meet corporate deadlines.
18. Ability to react calmly and effectively in emergency situations.
19. Ability to supervise personnel.

PHYSICAL, MENTAL, AND SPECIAL DEMANDS

THIS SECTION DESCRIBES HOW AN EMPLOYEE IN THIS POSITION CURRENTLY PERFORMS THE FUNCTIONS OF THIS POSITION. MODIFICATIONS TO THE MANNER IN WHICH THIS JOB MAY BE PERFORMED WILL BE REVIEWED ON A CASE-BY-CASE BASIS.

1. Ability to work at least 40 hours per week, and flexible hours and overtime as required.
2. Ability to sit for long periods, up to 8 hours.
3. Ability to use both hands in fine and gross manipulation of small tools (copier, computer, telephone, typewriter, calculator, safe, facsimile machine).
4. Ability to push and pull up to 10 lbs. (file cabinet drawers, computer paper boxes).
5. Ability to communicate clearly and see well enough to read handwritten and typewritten material.
6. Ability to lift and carry up to 25 lbs. dead weight.
7. Ability to stoop, kneel and bend daily.
8. Ability to reach, turn, and twist above and below the waist daily.
9. Ability to stand and walk on the facility grounds daily.
10. Ability to spend 10% of working time outside in temperatures varying from 30 F. to 105 F.
11. Ability to spend 90% of working time in an environment of continuous low voices and office machine noise typical of business office atmosphere.
12. Ability to handle a variety of repetitive tasks at a moderate level.
13. Prepared to occasionally handle electrical, mechanical, or equipment emergencies.

MACHINES, TOOLS, EQUIPMENT, AND OTHER WORK AIDES:

THIS SECTION DESCRIBES THOSE MACHINES, TOOLS, EQUIPMENT, AND OTHER WORK AIDES AN EMPLOYEE IN THIS POSITION MUST BE ABLE TO USE.

1. Computer system and printer.
2. Calculator/10-key
3. Typewriter.
4. Telephone and paging system.
5. Copy machine.
6. Fax.
7. Policies, procedures, plans and program manuals.