8 days old


Universal Health Services
Portland, OR 97201
  • Job Code

Cedar Hills Hospital and Outpatient Services - located just 15 minutes from downtown Portland - is a 98-bed, free-standing psychiatric hospital and outpatient center specializing in mental health and substance use disorder treatment. We provide a wide range of services and programs that offer evidence-based treatment proven to have positive outcomes for our patients. Our inpatient and outpatient services offer supportive and compassionate care through specialty programs that are tailored to meet the needs of our patients. Our mission is to provide safe, effective, and compassionate mental health and substance use treatment.

The Director of Performance Improvement directs the process of establishing a comprehensive and integrated performance improvement program which meets regulatory standards for both the hospital and the PHP/IOP components. The Director of Performance Improvement strives to emphasize an organization - wide approach in regards to continually meeting and/or exceeding licensing and accreditation standards, in order to delivery quality care and cost - effective treatment.

Job 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, Senior Staff meetings, and Compliance meetings. Route licensing and accreditation standards to leaders and managers as indicated.

-Establish a system for collecting and analyzing data related to performance improvement measures for both the inpatient hospital program and the outpatient behavioral health program. Consult with senior staff and directors in the development of department performance improvement quality measures. Maintain a list of hospital-wide performance improvement indicators which includes monthly and quarterly data, and prepare graphs of high risk processes.

-Update administrative policies and plans as indicated.

-Tabulate staff, patient, referral source, and/or physician satisfaction surveys.

-Keep binders on proactive risk assessments, incident reports, and Joint Commission corrective action as indicated.

-Keep monthly logs regarding complaints. Communicate with patients and families as indicated to follow-up on complaints. Assist in writing letters for mail-out from the CEO.

-Log ORYX data quarterly.

-Input Joint Commission Periodic Performance Review each year.

-In regards to the Risk Management program, tabulate and trend incident reports each month. Develop a reporting mechanism to the Safety and PI Committees.

-Hold PI Committee Meetings 10 to 12 times yearly. Develop and maintain a record on performance improvementactivities and keep PI Committee minutes in an accessible binder.

-Prepare and present the results of hospital-wide performance improvement activities to the Medical Staff each month.

-Prepare and present the results of hospital-wide performance improvement activities to the Governing Body each quarter.

-Prepare a monthly report of PI and Risk Management activities for CEO review.

Job Requirements

Education: Master's degree in nursing, social work, mental health/behavioral sciences, or related field.

Experience: A minimum of five (5) years experience directing performance improvement and risk management activities in a hospital, psychiatric hospital, or mental health treatment setting required.

Licensure: None required. RN or LMSW licensure preferred; Quality Professional certification preferred.

Additional: Knowledgeable regarding Joint Commission accreditation standards. Experience interpreting state and federal standards related to hospital operations.

Training: Successful completion of Crisis Management and Service Excellence training must occur within 90 days of employment and prior to assisting in any restraining procedures. May be required to work occasional overtime and flexible hours.


Posted: 2019-11-08 Expires: 2019-12-16

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Universal Health Services
Portland, OR 97201

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