DIR - PERFORMANCE IMPROVEMENT

About the role

The Director of Performance Improvement is responsible for the development, implementation, monitoring, and analysis of performance improvement projects and activities with a focus on improving patient safety and quality of care. The Director of Performance Improvement sets priorities for improvements aligned to ongoing strategic initiatives. They lead and direct process improvement activities that provide a more efficient and streamlined workflow in the hospital.

Responsibilities

• Provide a broad vision in the strategic development and direction of the performance improvement program for the hospital.
• Develop a facility-wide performance improvement plan which meets regulatory standards.
• Provide training to staff members on the concepts of performance improvement and the application to patient care via orientation of all new hires.
• Provide compliance consultation to managers through scheduled Performance Improvement Committee meetings, Department Manager meetings, and Compliance meetings.
• Provide updates and training on licensing and accreditation standards to leaders and managers as indicated.
• Establish a system for collecting and analyzing data related to QA/PI measures organization wide.
• Consult with Senior Management and Directors in the development of department performance improvement quality measures.
• Maintain a list of hospital-wide improvement indicators which includes monthly and quarterly data.
• Participate in Root Cause Analyses and Failure modes and effects analyses and debriefings.
• Oversee reporting and communication of quality improvement initiatives, quality and patient safety awareness, safety culture survey administration and patient satisfaction.
• Promote a culture of safety, high reliability, patient and staff engagement, and performance excellence.
• Oversee regulatory readiness and assists with preparing for Joint Commission, state licensing, CMS or other agencies.
• Maintain Joint Commission contact information and application.
• Career development opportunities within the company.

Qualifications

• Bachelor’s degree in nursing, social work, mental health/behavioral sciences or related field required.
• Relevant certifications in quality improvement, performance improvement, Lean, Six Sigma, or similar methodologies preferred.
• Minimum of 5–7 years of progressive experience in healthcare quality improvement, performance improvement, or operations management required.
• Minimum of 5 years of progressive experience directing performance improvement and risk management activities in a hospital, psychiatric hospital, or mental health treatment setting preferred.
• Experience in behavioral health, inpatient psychiatric care, crisis services, or emergency behavioral health settings strongly preferred.
• Demonstrated experience managing quality metrics, regulatory compliance, and cross-functional improvement initiatives.
• Experience leading multi-site or multi-unit operations preferred.
• Proven ability to analyze data, develop action plans, and drive measurable outcomes.
• Experience with accreditation and regulatory standards applicable to behavioral health services preferred.
• Strong leadership and team collaboration skills.
• Excellent analytical and problem-solving abilities.
• Proven ability to manage multiple priorities in a fast-paced environment.
• Knowledgeable regarding Joint Commission accreditation standards. Experience interpreting State and Federal standards related to hospital operations preferred.
• Strong project management and organizational skills.
• Effective communication and facilitation skills.
• Working knowledge of behavioral health regulations and compliance standards.
• Change management and resilience-building in high-acuity settings.
• Ability to influence others and drive change across multiple sites.
• High attention to detail and commitment to quality and patient safety.