Director of Quality & Performance Improvement

    October 19, 2021
    Dayton, Ohio
    Job Type


    Our client, a community based mental and behavioral health agency located 30 mins Northeast of Dayton, is looking to add to their Clinical Management Team with a Quality and Performance Improvement Director.  They really prefer someone local as they aren’t planning on offering relocation assistance.



    This position leads and directs all quality management activities across the organization including the following:  1) Performance Improvement, 2) Health Information Systems, 3) Medical Records, 4) TJC and Other Survey Coordination, 5) Program Evaluation, 6) Patients’ Rights, 7) Patient and Organizational Safety, 8) Risk Management, 9) Corporate Compliance, 10) Outcome-based care.



    • PERFORMANCE IMPROVEMENT & RISK MANAGEMENT-Develops, directs and oversees the implementation of the Quality Improvement program and Risk Management Plan. Reports QI/PI & Risk Management findings to Board of Trustees, leadership and outside entities as necessary.
    • Provide education, trainings and assistance to all service lines and committees.
    • Review and analyze current Qi/PI trends and existing activities to develop and implement needs
    • Develop, coordinate and implement trainings and educations, and oversee implementation of new processes and procedures to provide risk analysis to the organization.
    • Coordinate and oversee in the collection of data, and ensures the integrity and confidentiality of data.
    • MEDICAL RECORDS AND INFORMATION MANAGEMENT-Responsible for the oversight of the deficiency/delinquency analysis, appropriate storage and retrieval of client medical records, and keeps abreast of current laws and regulations regarding medical records and release of information.
    • SURVEY COORDINATION-Services as the liaison for all survey activities required by Joint Commission, CMS, OMHAS, ODH and any other applicable regulatory body.
    • Maintains knowledge and coordinates organizational compliance efforts regarding rules, standards, and regulations. Communicates changes and interpretations with all staff and leadership.
    • PROGRAM EVALUATION-Directs, oversees and coordinates data for all programs to recommend and establish information systems necessary to support programs.
    • PATIENT RIGHTS-Oversee and direct all activities related to patient and client rights, including oversight of Patient Advocate, reports of family/patient complaints and grievances and makes recommendations as appropriate. Maintains knowledge, laws and rules regarding patient rights programs.
    • PATIENT SAFETY-Develops and implements patient safety programs. Provides and reports responses to medical or health care related errors, both internally and externally.
    • CORPORATE COMPLIANCE-Develop and implement the Corporate Compliance Program, including training and education and reporting to the Board of Trustees, leadership and outside entities as necessary.

    Must keep in strictest confidence all patient information, including the fact that a person is a mental health patient at any program.

    Knowledge of budgeting, writing and implementing policies and procedures and general management and supervision of staff as required.

    Knowledgeable of national patient safety goals and incorporates them into essential functions.



    • Bachelors of Nursing or Master’s in Counseling, Social Work or Psychology (required)
    • Masters in Health Care Administration (preferred)
    • 3-5 Years’ Experience in Quality, PI or Risk Management in Healthcare
    • Experience with Joint Commission, federal and state (Ohio) regulations and standards



    • RN or Ohio Social Work or Counseling Licensure (required)
    • NVCI
    • CPR/First Aid



    Dayton, Ohio is a great city located at the Crossroads of America where the I-75 north/south meets the I-70 east-west, making it the perfect destination for meetings and conventions , family vacations and weekend stop-overs. Known as the Birthplace of Aviation , Dayton features a fantastic array of big city amenities coupled with mid-western charm and hospitality. When you visit our city, you'll be pleasantly surprised to find great attractions and historical sites, fantastic arts venues, a thriving downtown area, beautiful parks, a variety of sporting sites and fabulous shopping and dining.

    These are exciting times for the city as we are in the midst of an unprecedented revival. With a technology park sweeping the outskirts of town, recreational whitewater areas downtown, a planned family ice arena and two new downtown hospitals, the city is certainly moving forward. We are blessed with many of the same amenities as cities five times our size. We enjoy a symphony orchestra, performing arts center, a renowned university and a museum of art. Our natural resources, recreation areas and bike trails are among the finest in the region and there's more in the works. Where else can you find a state park and 1,200 acre lake just 10 minutes from downtown?

    Salary range is $70-85K.


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