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Performance Improvement Director/Risk Manager - (241806)

Universal Health Services

Job Code:
Universal Health Services
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Job Details

Deltek Talent Management - Performance Improvement Director/Risk Manager - (241806)

Job Details

Performance Improvement Director/Risk Manager - (241806)

Facility Name
Two Rivers Behavioral Health System
KANSAS CITY, MO 64133 US (Primary)
Career Area
Allied Health
Job Description

One of the nation’s 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 World’s Most Admired Companies by Fortune; ranked #276 on the Fortune 500, and listed #275 in Forbes inaugural ranking of America’s 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. Two Rivers Behavioral Health System has been providing services to the Kansas City metropolitan and surrounding area since 1986. Two Rivers is committed to providing children, adolescents and adults with compassionate behavioral health treatment based on the unique needs of the individual. We are a Joint Commission Accredited hospital providing inpatient, partial hospitalization and intensive outpatient services.

As a member of senior management this position ensures the development, implementation and evaluation of policies, programs and services consistent with the facility’s goals and objectives, and actively participates in a leadership role by consulting with facility management in designing and providing total patient care and services. The Director of Performance Improvement and Risk Management plans, organizes and directs all activities in compliance with hospital, state, federal and other accrediting and regulatory agency requirements. The individual in this role is responsible for coordinating the loss control efforts and making recommendations to minimize or eliminate exposure.

Job Requirements

Performance Improvement Responsibilities:

  • Provide direction and consultation to all staff members on the concepts of Quality Improvement in the application to patient care.

  • Consult with senior staff and directors in the development of department specific programs and quality measures which are within the standards of all applicable federal, state or local regulations governing health-care entities.

  • Develop a facility wide quality improvement plan that meets or exceeds all regulatory standards and develop performance measurement indicators.

  • Provide continuous support in the analysis of performance improvement goals and objectives, re establishing requirements that will facilitate continuous performance improvement

  • Review the results of quality improvement requirements with each department director, define performance improvement requirements for the department and involve other areas in the problem-solving process when situations span over more than one department.

  • Establish a system for collecting and analyzing statistical data relating to quality improvement measure and outcomes.

  • Ensure any detected deficiency in meeting quality improvement goals and objectives is addressed with appropriate management in a timely manner.

  • 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 record review).

  • Conduct quality improvement meetings on a regular basis to develop and continuously encourage a facility-wide team effort in meeting performance improvement efforts.

  • Design, implement and direct the Risk Management Program.

  • Develop and maintain a record on performance improvement activities and all committee minutes associated with performance improvement programs.

  • Support the Chief Executive Officer in preparing and presenting the result of facility performance improvement activities, as well as the functioning of all Medical Staff committees to the Consulting Board on a quarterly basis.

  • Monitor ongoing loss control components for effectiveness of identification and correction of potential risk factors as they relate to the hospital-wide risk management program.

  • Work with Medical Staff on assessment and improvement activities guiding them to develop monitors that evaluate the effectiveness of patient care along with the identification of problem areas that need improvement.

  • Report to the Medical Staff and Governing Body all activities from Performance Assessment and Improvement, and Risk and Safety.

  • Identify the educational needs of the Department Staff, the Professional Staff and other personnel and assist in the planning and teaching classes as needed.


Risk Management Responsibilities:

  • Develops implements and monitors a Risk Management Program in accordance with UHS T.E.R.M. program ensuring medical staff involvement to identify areas of adverse patient occurrences and problems in delivery of patient care.

  • Develops a systematic method for Risk Identification and Analysis for reporting patient related and visitor-premises adverse events. Utilizes physician-developed criteria to identify adverse effects in clinical high-risk areas. Develops and implements process to analyze and trend risk identification data.

  • Develops Loss Prevention and Risk Management Education Program. Provides education to new employees at orientation and conducts ongoing education and in-services on risk management topics annually.

  • Promotes Critical Risk Prevention Techniques to ensure appropriate release of information, informed consent and confidentiality issues are in accordance with established hospital policies and procedures. Reviews policies regularly.

  • Participates in the periodic review of the Bylaws and Credentialing procedures. Participates in the decision making process for privilege delineation.

  • Assists the Patient Advocate in Patient/Family Relations following an adverse event. Responds to patient/family complaints and addresses personal property losses when needed.

  • Leads Safety Committee and conducts safety rounds with other committee members to identify hazards and makes recommendations for corrective action.

  • Develops mechanism to ensure timely reporting of adverse clinical events, monitors percentages of identified occurrences that result in claims and regularly reports information to Medical Staff.

  • Receives quarterly reports and evaluates corrective actions. Reports results of monitoring and evaluation activities to Medical Staff Executive Committee. Reviews and summarizes monitoring and evaluation activities and maintains current records. Coordinates data retrieval for essential studies and reports. Ensures licensure and accreditation activities are in compliance with established standards and regulations. Obtains and distributes current information of all applicable licensing criteria and accreditation standards.

  • Familiar with State, and federal regulations/standards regarding environment of care and safety. Develops plans and conducts fire and emergency preparedness drills, including use of Hazard Vulnerability Analysis and community involvement. Maintains plans and policies in compliance with regulations regarding Safety, Life Safety, Security, Equipment Management, Utilities Management, and Emergency Preparedness.


This opportunity provides:

Challenging and rewarding work environment

Growth and development opportunities within UHS and its subsidiaries

Competitive Compensation

Education:  Graduate of an accredited school of nursing with bachelors degree preferred or other mental health related program with masters degree

Experience:  Five years clinical experience in a behavioral health facility with knowledge of high-risk areas. Previous experience in the performance improvement and quality assurance field.

Certifications/Licensure:  Lean - Six Sigma knowledge and experience a plus. Knowledge of hospital operations, risk identification, assessment and reduction and claims management, performance improvement initiatives.

Skills:  Strong communication skills (verbal, written, presentation)  Ability to manage multiple, competing priorities   Able to work collaboratively and effectively to achieve good outcomes   Must be responsive in managing issues that require timely management/oversight  

If you meet the above requirements and are looking for a rewarding career, please take a moment to share your background with us by applying online. UHS offers competitive compensation commensurate with experience and benefits programs including medical, dental, life insurance and 401k.

*UHS is a registered trademark of UHS of Delaware, Inc., the management company for Universal Health Services, Inc. and a wholly-owned subsidiary of Universal Health Services, Inc. Universal Health Services, Inc. is a holding company and operates through its subsidiaries including its management company, UHS of Delaware, Inc. All healthcare and management operations are conducted by subsidiaries of Universal Health Services, Inc. To the extent any reference to "UHS or UHS facilities" on this website including any statements, articles or other publications contained herein relates to our healthcare or management operations it is referring to Universal Health Services' subsidiaries including UHS of Delaware. Further, the terms "we," "us," "our" or "the company" in such context similarly refer to the operations of Universal Health Services' subsidiaries including UHS of Delaware. Any employment referenced in this website is not with Universal Health Services, Inc. but solely with one of its subsidiaries including but not limited to UHS of Delaware, Inc.

UHS is not accepting unsolicited assistance from search firms for this employment opportunity. Please, no phone calls or emails. All resumes submitted by search firms to any employee at UHS via-email, the Internet or in any form and/or method without a valid written search agreement in place for this position will be deemed the sole property of UHS. No fee will be paid in the event the candidate is hired by UHS as a result of the referral or through other means.

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