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Director, Risk Management/Performance Improvement

Universal Health Services

Job Code:
Universal Health Services
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Job Details

Director, Risk Management/Performance Improvement

Job Code:  227202
Facility: Kingwood Pines Hospital
Location: HOUSTON, TX US Southern
Region: Southern
Travel Involved: 0-10%
Job Type: Full Time
Job Level:  Experienced (Non-Manager)
Minimum Education Required: Associate Degree 
Skills: Health Care -> Behavioral Health, Administrative, Clinical Support
Quality Assurance -> Joint Commission Regulations
Customer Service -> Face-to-Face Support
Human Resources -> Management
Category: Professionals
FTE: 1.0
Position Summary:

Position Summary
Universal Health Services, Inc. (UHS)
is one of the nation’s largest and most respected health care management companies, operating through its subsidiaries acute care hospitals, behavioral health facilities and ambulatory centers nationwide. Founded in 1978, UHS subsidiaries now have more than 65,000 employees. The UHS business strategy is to build or purchase health care properties in rapidly growing markets and create a strong franchise based on exceptional service and effective cost control. Our success comes from a responsive management style and a service philosophy based on integrity, competence and compassion.

Kingwood Pines Hospital a 116 bed facility located in the beautiful residential Kingwood community. We are located about 30 miles northeast of the Houston Medical Center. The hospital provides 24-hour emergency services. We serve children, adolescents, adults for psychiatric and behavioral health. The hospital also has services in intensive outpatient and partial hospital program services. Kingwood Pines Hospital currently has a Director of Risk Management/Performance Improvement position available. The candidate selected will be responsible for the following:

Purpose: Coordinates overall QAPI Program and provides education to staff regarding Performance Improvement and Risk Management. Coordinates Risk Management data for appropriate evaluation and risk trend analysis. Ensures that patient’s rights are adhered to and patient grievances are resolved. Provides executive direction and oversight to departments of responsibility.

1. Oversees facility Risk management Program, Provide in-services in Risk Management in monthly new hire orientations as needed;
2. Coordinates Risk Management data for evaluation, trending and reporting;
3. Cross trained with Director of Performance of Improvement to oversee this function in case of prolonged absence of Director of PI.
4. Manages facility incident reports.
5. Participates with leaders from the governing body, management, medical and allied staff to improve the quality and appropriateness of patient care. Attend meetings including but not limited to, Pharmacy & Therapeutics, Safety, QAPI, Nurse Management, Research, Medical Executive;
6. Ensures patient confidentiality is maintained and act to safeguard PHI;
7. Implement the T.E.R.M. Risk Management program to enhance patient care and safety reduce liability situations through ongoing assessment and evaluation of general hospital and clinical areas of risk
8. Conduct intensive analysis/root cause analysis in a pro-active manner to address pertinent patient care safety issues/risks, serious incidents (Level III and Level IV), and in response to a near miss or sentinel event
9. Adheres to the Service Excellence Standards.
10. Risk Manager’s role as the on-site representative of the Corporate Insurance Program in the management of claims and litigation of professional and general liability issues.
11. Works closely with corporate risk manager in establishing new practices based on corporate wide patient safety alerts.
12. Facilitate monthly patient safety council meeting and keeps meeting minutes.

Customers Served:
Medical staff, allied health professional staff, external information requestors, all hospital staff, managed care, community.


1. Good knowledge of Risk Management programs, principles and policies;
2. Knowledge of basic Patient’s Rights;
3. Ability to analyze and interpret data;
4. Ability to coordinate and integrate all QAPI and Risk Management activities within the hospital;
5. Maintain confidentiality of patient information;
6. Excellent communication skills including investigative, problem solving and issue resolution;
7. Knowledge and understanding of Joint Commission, HIPAA and other applicable licensing agency regulations;
8. Proficient in computer software including, but not limited to, Excel, Word, Outlook, HMS.

College degree in health care related field


Requires a minimum of 3 years of experience in Quality Management, preferably in a psychiatric/chemical dependency setting.



Participates in therapeutic crisis intervention, which involves some personal risk when dealing with physically aggressive patients.

Other Hazards:
This position may, from time to time, require that patients outside the normal age group(s) as stated above be cared for. In this event, the employee should consult with his/her direct supervisor to be directed to available resources to provide the appropriate care.

Physical Requirements:
Full range of body motion including handling and lifting patients. Manual and finger dexterity. Hand-eye coordination. Ability to run. Ability to assist in restraining patients weighing up to 250 pounds. Ability to lift and carry items weighing up to 50 pounds. Ability to perform cardiopulmonary resuscitation. Ability to drive a vehicle. Ability to walk 6+ hours per day, frequently standing, bending, stooping and reaching to check or move equipment and assist patients. Hearing and vision sufficient to perform essential functions. Emotional stability necessary to perform essential functions. Ability to speak clearly. Ability to write legibly.

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