Manager of Performance Improvement

Dover Behavioral Health - Manager of Performance Improvement

Position Summary:

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

Program 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).

QUALIFICATIONS:

Experience: Experience in managing quality and risk, as well as enhancing organizational performance in an acute medical or psychiatric treatment environment. A bachelor's degree is preferred but not mandatory.

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.

Equal Employment Opportunity

It is the policy of the facility to provide equal opportunity in employment to all employees and applicants for employment. No person will be discriminated against in employment based on 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.

Americans with Disabilities Act

Applicants as well as employees who are or become disabled must be able to perform the essential job functions either unaided or with reasonable accommodation. The organization shall determine reasonable accommodation on a case-by-case basis in accordance with applicable law.

Service Excellence.

Service excellence is a part of all we do. Our standards include:

Treat everyone as a guest by making a good first impression, anticipating needs and displaying service recovery skills.

Demonstrate professionalism and excellence by looking professional, being accountable for actions and delivering excellence in our everyday work.

Practice teamwork by participating in decision making and process improvement, communicating effectively and focusing on the problem/issue, not the person.