DIRECTOR - PERFORMANCE IMPROVEMENT (RN License required)

Responsibilities

Performance Improvement Director Opportunity

West Oaks Hospital has provided psychiatric care to the Houston area and surrounding communities for over four decades. Our 176-bed acute care facility is fully accredited and included a 16-bed residential treatment center for adult chemical dependency.

We offer a broad range of behavioral health programs for children, adolescents and adults. Treatment is offered at multiple levels of care including inpatient, partial hospitalization and intensive outpatient.

We are available 24 hours a day, seven days a week to assist you and answer your questions about treatment options and insurance coverage. The hospital is easily accessible off the Southwest Freeway near the Galleria.

Visit us online at: https://westoakshospital.com/

West Oaks Hospital is seeking a dynamic and talented Director, Performance Improvement to join our team of compassionate, dedicated professionals. The Director of Performance Improvement (DPI) has broad responsibility to ensure the hospital’s compliance at all times with all Joint Commission, CMS, TDSHS and other regulatory agencies standards and requirements. The DPI is responsible for staff training and education on the hospital’s performance initiatives and measures including outcomes measurement and reporting.

Job Duties/Responsibilities:

• Lead regulatory compliance with Joint Commission, CMS, DHHS and other applicable agencies.
• Monitor PI indicators and action plans.
• Coordinate, review and update hospital Performance Improvement Plans annually.
• Lead Performance Improvement Council monthly meetings. Prepare agenda; comply and present aggregate data and statistical reports; and take minutes.
• Submit and present quarterly PI report to Board of Directors.
• Lead and coordinate PI initiatives and activities, to include survey readiness.
• Ensure the hospital meets Joint Commission, CMS, and state regulatory requirements.
• Develop and implement a Performance Improvement Plan, evaluate the results monthly and report the results to PI Committee, MEC and BOG.
• Ensure that all deficiencies identified through the Performance Improvement analysis are addressed with appropriate problem solving actions
• Analyze statistical data of the hospital to determine and respond to trends.
• Consult with senior staff and directors in the development of department specific programs and quality measures which are within the standards of Joint Commission, CMS, TDSHS, OSHA regulations and all other applicable federal, state or local law/regulations governing health-care entities.
• Prepares and submits monthly PI data to UHS by the 10th of each month or when required.
• Maintain and monitor Joint Commission web site, coordinate all regulatory site visits, prepares and submits Corrective Action Plans in a timely manner.

Benefit Highlights:

Loan Forgiveness Program
Relocation Bonus as needed
Challenging and rewarding work environment
Competitive Compensation & Generous Paid Time Off
Excellent Medical, Dental, Vision and Prescription Drug Plans
401(K) with company match and discounted stock plan
SoFi Student Loan Refinancing Program
Career development opportunities within UHS and its 300+ Subsidiaries!
More information is available on our Benefits Guest Website: uhsguest.com

About Universal Health Services

One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune 500® corporation, annual revenues during 2025 were $17.4 billion. In 2026, UHS was again recognized as one of Fortune World’s Most Admired Companies™ and in 2025, was listed in Forbes ranking of America’s Largest Public Companies.

Headquartered in King of Prussia, PA, UHS has approximately 101,500 employees and continues to grow through its subsidiaries. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located in 40 U.S. states, Washington, D.C., Puerto Rico and the United Kingdom. For additional information visit www.uhs.com.

Qualifications

Requirements:

Bachelor’s Degree in related field. Preferred Master’s degree in Nursing.
Four (4) years of professional experience in performance improvement and or quality management/improving organizational performance within an acute medical or psychiatric treatment setting.
Experience may be substituted with education on a 1:1 basis
CPR and de-escalation certification
RN License, Required

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.

We believe that diversity and inclusion among our teammates is critical to our success.

Avoid and Report Recruitment Scams

We are aware of a scam whereby imposters are posing as Recruiters from UHS, and our subsidiary hospitals and facilities. Beware of anyone requesting financial or personal information.

At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc.

If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.

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