Quality Assurance Director

Description

GENERAL SUMMARY

Coordinates/Leads the Agency’s Continuous Quality/Performance Improvement to ensure a proactive approach to the revision, provision and development of treatment services that meet or exceed compliance with accrediting standards (CARF), other regulatory bodies and the Agency’s strategic plans. Ensures Agency’s required codes of ethics and values are practiced in daily operations.  

• MINIMUM QUALIFICATIONS

Master’s in Behavioral Health Science with 3 years of experience in Quality Improvement and Accreditation 

And/or Bachelor’s Degree in Behavioral Health Science with 5 years of experience both required to have CARF survey experience.

Requirements

I. Coordinate and facilitate the Agency-wide Quality Improvement Program including but not limited to:

• Collaborates   with the Clinical Quality Assurance Director to ensure that there is a   written annual plan for the Quality Improvement Plan which describes the   Agency’s performance goals, areas needing improvement, strategies to achieve, and ongoing mechanisms to review, renew, or revise goals, strategy or tactics.
• Develops/revises   Agency-wide written policy and procedures, other documents, written plans as   required by external accreditation or other regulatory entities. Ensures Agency stays informed of changes   and remains current and in compliance with all regulatory requirements.
• Chairs   the Quality Improvement Committee and oversees all sub committees. Continually monitors and evaluates the   Quality Improvement program and implements corrective actions as needed to achieve optimal outcomes.
• Chairs   the Recovery Oriented System of Care Committee. Collaborates with the Clinical Quality   Assurance Director to facilitate internal ROSC chart audits and client   interviews.
• Provides   direction to various Agency departmental groups with regard to their   respective Quality Improvement activities, monitors compliance and reports   deficiencies to QI Committee.
• Serves   as the central coordinating point for all contract monitoring, corrective   action and performance improvement plans.
• Collaborates   with the Clinical Director and Information Technology Director to develop and   maintain automated databases for Quality/Performance and accreditation data; provides periodic statistical and summary reports as required. 
• Oversees Risk Management/ Facilities and Safety
• Responsible   for agency licensing renewals 

II. Participates in all Agency Quality   Improvement committees and sub-committees as directed:

• Provides directions for the continuous Quality Improvement committee as appropriate. 
• In   conjunction with the appropriate Quality Improvement committee(s), continually reviews data related to service delivery in order to determine committee agenda(s) and identifying areas requiring further support, training, review or revision. 
• Tracks, monitors the status of identified problems to ensure their improvement or resolution.
• Maintains   Quality Improvement tracking systems for all committee meetings reflecting   issues discussed recommended action, follow-up status and the designated   party (ies) responsible for the appropriate follow-up.

III. Coordinates,  Coordinates,   gathers, disseminates and documents information to facilitate compliance with   requirements for accreditation surveys and other regulatory and contract   entities: 

• Effectively plans and coordinates the preparation of on-site accreditation and monitoring  surveys.
• Demonstrates   effectiveness in presenting and/or providing information to program managers, as needed, to assure compliance with accreditation/statutory/contract   requirements and/or standards.
• Provides   assistance to staff in monitoring and evaluating the performance of care in their respective programs; assists in the development and revision of   policies as required and/or indicated.
• Maintains   current knowledge of accreditation standards and the survey process for the Commission on Accreditation of Rehabilitation Facilities (CARF).
• Effectively provides ongoing information to management on Quality/Performance activities and provides timely status reports on accreditation preparedness, CAPs and other related issues.
• This position will oversee the staff who is assigned as the official Single Point of Contact, which is designated to   coordinate the provision of auxiliary aids and services to the deaf and hard   of hearing.

 IV. Participates   in t