Director of Clinical Performance Improvement - Behavioral Sciences Campus

Position Summary:

The Director of Clinical Performance Improvement will direct and plan the implementation and analysis of all clinical and quality improvement activities for UTHealth Houston's Behavioral Sciences Campus.  The Director will provide overall administrative direction and oversight to the following functions:Patient Relations, Infection Control, Clinical Performance Improvement and Regulatory functions (including CMS and Joint Commission Standards). The Director will oversee, coordinate, and direct all functions of the Clinical Risk Management Program.
 

Position Key Accountabilities:

1.    Provides overall direction for the development and implementation of the Performance Improvement Plan for the Center’s inpatient and other clinical services. Directs the program with the goal of ensuring that clinical performance improvement occurs as a result of evidence based quality improvement activities. Develops, coordinates, and oversees the clinical risk management and prevention including identifying risk, conducting investigations, and making appropriate recommendations to correct and or eliminate deficiencies that may adversely affect patients, visitors and employees. Serves as risk management liaison with UT Risk Management
2.    Researches and recommends appropriate strategies and best practices for improving safe and quality care in support of institutional strategic goals, clinical operations and programs.
3.    Maintains continued Regulatory survey readiness with regards to CMS, State and The Joint Commission Standards.  Conducts and oversees The Joint Commission mock surveys, performs analysis of survey outcomes and reports findings and develops appropriate action plans in coordination with key clinical managers and administration.
4.    Prepares clinical performance improvement initiatives and outcomes reports for the administration and other governing bodies.
5.    Participates in, and chairs major hospital-wide committees and special projects. Mentors Center staff and leadership on principles of Quality/ Performance Improvement.
6.    Serves as the lead hospital contact during regulatory surveys (Including The Joint Commission, DSHS, Disability Rights, CMS and other regulatory related unannounced visits); provides all requested reports and documents as well as answers questions for surveyors regarding all hospital procedures. Produces all follow- up reports and status updates to findings identified during survey and ensures action items are completed in required timeframes..
7.    Provides education support to all of the Center’s departments including medical staff with regards to quality improvement, accreditation standards, and other regulatory standards. 
8.    Develops the system for defining and monitoring clinical performance improvement departmental indicators.  Analyzes and summarizes clinical performance improvement data from a clinical perspective and prepares and distributes information to internal committees and governing bodies. 
9.    Oversees the dissemination of ongoing patient satisfaction survey results. Leads performance improvement initiatives based on survey results.
10.    Ensures timely responses by Patient Relations Department in regard to patient/ family member complaints and grievances.
11.    Directs the Center’s infection prevention and control program, and ensures regular reporting from Infection Prevention Department to required committees and departments.
12.    Participates  with other Center leaders, in the development of mission, vision, values, strategic plans, and policies. 
13.    Provides oversight for the coordination, development, implementation, and evaluations of the following plans: Patient Relations, Clinical Risk Management,  Infection Control, Patient Safety and Performance Improvement. 
14.    Ensures that organizational-wide clinical policies and procedures are reviewed and updated to reflect best practices and regulatory body requirements. 
15.    Manages Human Resources activities of department in regards to: budget recruiting and selection, hiring and termination, training, professional development, mentoring, counseling, performance evaluations, and salary planning. 
16.    Responsible for the design, execution and effectiveness of a system of internal controls which provides reasonable assurance that operations are effective and efficient, assets are safeguarded; financial information is reliable and compliant with applicable laws, regulations, policies and procedures. 
17.    Performs other duties as assigned.