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Havenwyck Hospital Auburn Hills Full-Time
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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.

What do our employees value at UHS?

An environment that puts patient care first. Competitive salary and comprehensive benefits package. Supportive and responsive leadership. The opportunity to grow, learn, and advance in your career. There are very robust continuing education options and opportunities for leadership development as the Director of Quality, Outcomes and Regulatory with UHS.

Havenwyck Hospital is a 243 bed, Joint Commission accredited and licensed psychiatric and substance abuse facility. We specializing in providing behavioral health and substance abuse treatment and are located in Auburn Hills overlooking Lake Galloway. For more information, please visit our website at havenwyckhospital.com.

Mission Statement: To provide individualized, quality behavioral health care, in a safe and secure environment where dignity and respect are upheld by our team of dedicated, caring, professional staff, in a cost-effective manner.

The Director of Quality, Outcomes and Regulatory reports directly to the Chief Executive Officer and is primarily responsible for overseeing the development, implementation, coordination, and aggregation of the hospital wide Performance Improvement Plan.

Havenwyck Hospital is seeking a dynamic and talented licensed Director of Quality, Outcomes and Regulatory to join our team of compassionate, dedicated professionals.

Duties include but are not limited to:

  • Collects, coordinates and maintains informational reports from all departments and committees as outlined in the Performance Improvement (PI) Plan.

  • Coordinates and monitors the hospital wide PI Plan in order to maintain compliance with The Joint Commission, CMMS, and other regulatory agencies.

  • Evaluates and improves the systems, forms, procedures, methods, and motions used in accomplishing all PI work.

  • Prepares reports for all Board of Director meetings, Medical Executive Staff meetings, and Medical Staff meetings.

  • Assists Medical Staff in evaluating the quality of patient care and in developing criteria and methods for such evaluation.

  • Provides ongoing communication, resources, education, and aggregated data/information to all department managers, related to issues involving quality, safety, and survey readiness.

  • Assist with annual evaluation (and revision if necessary) of the PI Plan.

  • Plans, develops, and presents in-services relevant to PI and survey readiness as necessary.

  • Responsible for the review, development, and implementation of the department policies and procedures.

  • Serves as the facility’s Compliance Officer.

  • Ensures the hospital’s environment is safe, clean, and well organized.  Makes recommendations for resources and adequate space.  Submits requests for repairs and for required equipment.  Conducts quarterly safety rounds.

  • Maintains knowledge and understanding of The Joint Commission (CAMH, CAMBH) and CMMS Standards and strategies for compliance. Acts as the facility liaison during the survey process including other applicable state and federal regulatory agencies. Ensures timely response and oversees development and implementation of any required corrective actions. Assigns tasks as necessary to other departmental managers to assist in overall regulatory compliance.

  • Reviews and analyzes root causes, patterns, or trends in data collection and informs applicable Facility management staff; helps to identify and implement corrective action and performance improvement processes.

  • Provides continuous support in the analysis of performance improvement initiatives and re-establishing requirements which will facilitate continuous improvement. Fosters the development and tracking of performance indicators at the departmental level; encourages a facility-wide team effort in meeting performance improvement goals.

Job Requirements
  • Bachelor’s degree in Human or Health Services field required.  MSN or advanced degree preferred.
  • Valid licensure in the State of Michigan as a RN, NP, MSW, MA, or PhD required.
  • At least five years clinical experience required in a related setting.
  • 3 - 5 years of management experience preferred.
  • Relevant experience and demonstrated skill in data aggregation and interpretation, analysis and process improvement required.
  • Experience collecting and interpreting patient information required.
  • Experience collecting and analyzing performance and incident data at the medical staff and organizational level. 
  • Thorough knowledge of regulatory and accrediting agency standards, rules and regulations (i.e., The Joint Commission, CMMS, DHHS, etc.) required.
  • Proficient in Microsoft Word, Excel and PowerPoint applications required. 
  • Employees must be in good standing (employment/corrective action history, performance evaluations, etc.) to be considered for internal transfer.

This opportunity provides the following:

  • * UHS is Challenging and rewarding work environment
  • Growth and development opportunities within UHS and its subsidiaries
  • Competitive Compensation
  • Excellent Medical, Dental, Vision and Prescription Drug Plan
  • 401k plan with company match
  • Generous Paid Time Off

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.


Recommended skills

Business Process Improvement
Corrective And Preventive Actions
Performance Improvement
Health Care
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Havenwyck Hospital is a Joint Commission-accredited and licensed psychiatric and substance abuse facility overlooking Lake Galloway in Auburn Hills, Michigan. We specialize in providing behavioral health and substance abuse services to children, adolescents and adults.

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