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Universal Health Services

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Universal Health Services
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Job Details

Deltek Talent Management - DIR - PERFORMANCE IMPROVEMENT - (17644)

Job Details


Facility Name
LANCASTER, PA 17603 US (Primary)
Career Area
Job Description

Lancaster Behavioral Health Hospital (LBHH) is a brand new 126 bed inpatient psychiatric hospital opening in the summer of 2018. The facility is a joint venture between Lancaster General Health/Penn Medicine and Universal Health Services.

Lancaster General Health/Penn Medicine (LG Health/Penn Medicine), a member of the University of Pennsylvania Health System (Penn Medicine), is a 631-licensed bed not-for-profit health system with a comprehensive network of care encompassing Lancaster General Hospital (LGH), Women & Babies Hospital and the Lancaster Rehabilitation Hospital (in partnership with Kindred Healthcare). Our membership in Penn Medicine brings together the strengths of a world-renowned, not-for-profit academic medical center and a nationally recognized, not-for-profit community healthcare system.

Outpatient services are provided at the Downtown Outpatient and Suburban Outpatient Pavilions, along with additional outpatient centers and Express and Urgent Care locations throughout the region. Lancaster General Health Physicians is a network of more than 300 primary-care and specialty physicians, at more than 40 offices throughout the region. Pennsylvania College of Health Sciences is a private, co-educational, Middle States-accredited four-year college offering a variety of associate and baccalaureate degree and certification programs in healthcare.

A four time designated Magnet hospital for nursing excellence, LGH has been recognized regionally and nationally for clinical excellence and patient safety; and ranked nationally by U.S. News & World Report as one of the nation’s best hospitals in 2015-16 in three specialties.

Universal Health Services, Inc. (UHS) is one of the nation’s largest and most respected hospital companies in the United States. Steadily growing from a startup to an esteemed Fortune 500 corporation, UHS today has annual revenue nearing $10 billion. Our operating philosophy is to 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.

LBHH will be a six unit facility that provides highly specialized services which includes multi-disciplinary teams providing high quality, innovative, and evidence based care to adolescents and adults.

We will treat every person who seeks our services with dignity and respect. We will practice collaboration and not control. We will provide evidence based treatments and our core competencies and skills will reflect best practices.

We strive to attract employees who are passionate about behavioral health.

Come make a difference with us.



The Director of Quality is responsible for overseeing and monitory the facility-wide Quality Management/Performance Improvement program to ensure compliance with all accreditation and regulatory agencies including the Joint commission (TJC), Centers of Medicare and Medicaid Services (CMS), Pennsylvania regulations (OMHSAS) as well as any other applicable state and federal laws and regulations governing mental health care facilities.


Key Responsibilities include:

  • Initiates and supports departmental, facility, and companywide quality management/performance improvement goals and objectives.

  • Prepares hospital to be in a constant state of readiness for on-site surveyors, planned or unannounced, not limited to TJC, CMS and Pennsylvania Department of Health.

  • Ensures plans of correction are submitted timely.

  • Ensure 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) to support Credentialing.

  • Co-chairs meetings Quality Council, Peer/Quality Review committees. Attends Medical Staff, Medical Executive, Board of Trustees and ad hoc meetings as needed. Preserves binders for minutes and supporting documentation.

  • Oversees the hospital risk management, medical records, credentials, and utilization functions.

    This position reports to the Chief Executive Officer and is an integral part of the hospital leadership team.


Job Requirements

Education:  Master’s Degree or diploma from an accredited program or university in a healthcare related field.

Experience:  Two (2) years’ experience in quality management, improving organizational performance within an acute psychiatric setting.

Licensure/Certification:  Certified Professional in Healthcare Quality (CPHQ) preferred.

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