1+ months


Universal Health Services
Fremont, CA 94538
  • Job Code

Be a difference maker at Fremont Hospital! Our hospital can provide a place for you to thrive and continue your professional development in healthcare or ancillary support roles.

We are currently hiring for a Director of Performance Improvement. The Director, Performance Improvement develops, manages, and integrates the Quality Management/Performance Improvement program to ensure compliance with all accreditation and regulatory agencies including The Joint Commission (TJC), Center for Medicare and Medicaid Services (CMS), California Department of Public Health (CDPH) as well as any other applicable state and federal laws and regulations governing mental health care facilities.

  • Responsible for coordinating and managing hospital wide quality management/performance improvement goals and activities including continued survey readiness for on-site surveyors, planned or unannounced, not limited to TJC, CMS and CDPH.
  • Responsible for managing the implementation and monitoring of the Performance Improvement Program company-wide, which meets or exceeds all regulatory standards and develop performance measurement indicators. Identifies aspects of the program in need of improvement and initiating actions to correct identified deficiencies.
  • Understands and promotes Fremont Hospitals PI methodology of Plan, Do, Check and Act.
  • Ensures plans of correction are submitted timely. Ensures interdisciplinary departments adhere to and follow-up with plans, while providing information when necessary to show evidence of compliance or data to show improvements over time.
  • Supports the chair of the Peer/Quality Review committee for Medical Staff. Collects data for Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) to support Credentialing.
  • Responsible for patient relations/grievances that address quality of care, quality of service, and patient safety issues.
  • Coordinates and monitors interdisciplinary teams progress on compliance to TJC Standards and CMS Conditions of Participation.
  • Co-chairs meetings Quality Council, Peer/Quality Review committees. Attends Medical Staff, Medical Executive, Governing Board and ad hoc meetings as needed. Preserves binders for minutes and supporting documentation.
  • Provides direction and consultation to all staff members on the concepts of Total Quality Management (TQM) and the use of TQM tools in the application to patient care.
  • Performs other duties as assigned.

Fremont Hospital is a fully accredited, 148-bed private inpatient psychiatric hospital providing quality care for adolescents, adults and seniors. Dedicated to hope, healing and recovery, we are working to transform the delivery of healthcare. Fremont Hospital is located in the city of Fremonts medical community, easily accessible to bay area residents. Our facility provides a continuum of services through assessments, inpatient psychiatric hospitalization, and intensive outpatient programs. We are committed to meeting the diverse needs of the communities we serve. Your passion, inspiration and talents are invaluable tools to recovering those struggling with mental illness.

About UHS:

One of the nations largest and most respected hospital companies, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. Steadily growing from a startup to an esteemed Fortune 500 corporation, UHS today has annual revenue nearing $10 billion. In 2017, UHS was recognized as one of the Worlds Most Admired Companies by Fortune; ranked #276 on the Fortune 500, and listed #275 in Forbes inaugural ranking of Americas Top 500 Public Companies.

Our operating philosophy is as effective today as it was 40 years ago: Build or acquire high quality hospitals in rapidly growing markets, invest in the people and equipment needed to allow each facility to thrive, and become the leading healthcare provider in each community we serve. Headquartered in King of Prussia, PA, UHS has more than 81,000 employees and through its subsidiaries operates more than 320 acute care hospitals, behavioral health facilities and ambulatory centers in the United States, Puerto Rico, the U.S. Virgin Islands and the United Kingdom. If you have the desire to pursue a career in healthcare and provide compassionate care we want to hear from you!

Fremont Hospital offers comprehensive benefits, such as:

  • Challenging and rewarding work environment
  • Competitive Compensation
  • Excellent Medical, Dental, Vision, and Prescription Drug Plan
  • Generous Paid Time Off
  • 401(K) with company match and discounted stock plan
Job Requirements

Education: Bachelors Degree or diploma from an accredited program or university in a healthcare related field. Bachelors Degree in Nursing (BSN), preferred.


  • Two (2) years experience in quality management, improving organizational performance within an acute psychiatric setting preferred.
  • Experience as an RN preferred.
  • A strong knowledge of TJC, CMS, Occupational Safety and Health Administration (OSHA) and Patient Rights standards.
  • Certification may be current for CPR with AED and presented to Human Resources upon hire. Position may successfully complete the Fremont Hospitals non-violent Crisis Prevention Intervention (CPI) training and verbal de-escalation training courses within 90 days of employment, prior to assisting with preventative intervention measures and annually. Able to work overtime and flexible hours as needed.

Licensure: Current California RN license or ability to obtain, preferred.


Posted: 2019-11-27 Expires: 2020-02-26

Before you go...

Our free job seeker tools include alerts for new jobs, saving your favorites, optimized job matching, and more! Just enter your email below.

Share this job:


Universal Health Services
Fremont, CA 94538

Join us to start saving your Favorite Jobs!

Sign In Create Account
Powered ByCareerCast