Director of Performance Improvement

New Lenox, IL 60451

Employment Type: Full-Time Direct Hire Category: Executive Level/Administration Job Number: 3154

PsychPros is seeking a Director of Performance Improvement for a psychiatric hospital in New Lenox, Illinois. The Director of Performance Improvement (PI), Risk Management, and Patient Advocate assists the leadership, medical staff and Quality Council in designing, planning, implementing, and overseeing a comprehensive and integrated program.

Education:  Bachelor’ s degree or equivalent in Nursing, or in a health-related field, preferred.

Experience:  2-3 years’ experience in a healthcare or behavioral health setting, involving quality improvement, preferred.

Additional Requirements:  Licensed to practice nursing or mental health related field in the State of Illinois preferred. Computers skills involving knowledge of Excel spreadsheets, and business writing.

  • Supervising and supporting performance improvement activities on a daily basis, and assure that action is taken as needed, and as authorized, by organization policies and procedures.
  • Receiving and reviewing department/service performance measures and documentation to evaluate performance improvement activities and coordinate reports of findings on daily, monthly, and annual basis to the Quality Council, Medical Executive Committee, and Board.
  • Maintain records of the performance improvement, performance measures, and statistical tools used to describe studies performed, or methodology.
  • Advise and assist all departments/services and committees accountable for performance improvement activities.
  • Prepares, coordinates and documents PI meetings.
  • Maintain a record of all completed reviews, evaluations, and process improvement team activities.
  • Review all incident reports, patient/physician surveys, and patient complaints to determine the presence, or absence of, patterns and/or trends, or opportunities for improvement in patient care outcomes, as well as the appropriateness of corrective action.
  • Assist with Joint Commission, CMS, OSHA, and state surveys.
  • Responsible for collection of data and submission of results for ORYX monitoring for The Joint Commission and IPF for CMS.
  • Responsible for receipt and logging all official correspondence from all official and accrediting agencies.
  • Responsible to notify administration and corporate compliance of all investigative requests, questionnaires, audit requests, and all other official communication from outside agencies.
  • Responsible to compose and to submit to administration a rough draft response to all official correspondence.
  • Responsible for submissions to Joint Commission, CMS, and state, after receiving approval from Corporate Compliance.
  • Fulfill all functions of the patient advocate.
  • Contact any patient requesting patient advocate with-in the first working day of request.
  • Contacts any individual filing a patient grievance with-in the first working day following the receipt of the grievance.
  • Follows the patient grievance process, ensuring the investigation of the grievance, ensuring appropriate actions are taken, documenting actions, and informing the patient/representatives of results of investigation, and actions taken.
  • Maintain the grievance log.
  • Ensure that the patient rights and responsibilities are posted, answers the patients questions about rights, and ensures that the patient’ s rights are respected.
  • Responsible to keep Administration and Corporate Compliance aware of all compliance issues.
  • Monitor all requests for premature discharge.

Competitive salary and bonus package. Please forward an updated resume to for consideration.



Daniel Fries

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