Project Director of Quality

Overview

PURPOSE STATEMENT:

The Project Director of Quality (PDQ) will be supporting and traveling to Acadia facilities across the country with a typical focus on their assigned Group.  The PDQ may act as the Director of Quality at facilities that have a vacancy and/or will provide periodic extended onsite support to an interim leader and will help to facilitate a smooth transition once a permanent Quality leader is hired. 

Overall, the PDQ is responsible for ensuring patient safety and superior quality of care as measured by survey readiness, treatment program fidelity, and compliance with state and federal laws and regulations and accreditation standards.  As such, the Director is responsible for leading and overseeing all aspects of policy development; comprehensive implementation of Acadia’s prescribed clinical protocols, operational quality oversight standards, and programmatic expectations; critical incident reporting; regulatory engagement, including development and submission of plans of correction; certification achievement and maintenance; oversight of the quality assurance and process improvement (QAPI) program; and on-going regulatory readiness strategies at the facility. Through routine physical presence in patient care areas, data analysis and documentation monitoring, and intentional sharing of deep subject-matter expertise, the Director will ensure a proactive, multidisciplinary focus on quality and excellence within the facility.

Responsibilities

 

ESSENTIAL FUNCTIONS:

The PDQ will work under the direction of the Group Quality Director and will primarily serve as the facility-based Director of Quality and essential functions will include but not be limited to: 

• Monitor the day-to-day regulatory readiness, patient safety, and service excellence across the facility.
• QAPI program oversight and management – follow and develop processes for identification, collection, and analysis of quality performance data.
  • Utilize collected data regarding the outcome of activities for delivering continuously improving services.
  • Conduct annual preparation and evaluation of the facility QAPI Program.
  • Complete process improvement projects and incorporate the results into patient care improvements.
  • Submit quality scorecard data to Acadia corporate office as requested.
• Coordinate the abstraction of clinical data according to Joint Commission specifications and data entry via vendor database for Inpatient Psychiatric Core Measures (ex. national quality measures such as HBIPS).
• Identify key aspects of care relevant indicators and evaluation of data using formal and informal feedback from consumers of services and other collateral sources is aggregated and used to improve management strategies and service delivery practices.
• Lead/coordinate data collection and analysis from all departments within the facility.
• Prepare and present program data trends and action plans to the monthly Quality Council and quarterly to the Medical Executive Committee and the Governing Board.
• Regulatory preparedness – implement sustainable survey preparation and ongoing monitoring processes, including facility-wide auditing and early-issue identification, to maximize achievement of zero- or standard-level survey outcomes.

• Ensure facility compliance with policies and applicable standards as required by regulatory/accrediting bodies.
• Facility leader and subject matter expert on high reliability principles and strategies to achieve zero harm.
• Clinical program excellence – assess fidelity and identify root-causes for gaps/lapses in fidelity to Acadia standards. Support other departments in developing and implementing remediation and improvement plans to achieve fidelity to Acadia’s expected practices, including all elements of treatment program implementation.
• Develop, review, and educate on internal clinical procedures and appropriate use of outcome evaluation tools and the associated results – including patient experience data and other quality scorecard metrics – to ensure continuous quality improvement and ongoing compliance with federal, state, and third-party regulatory requirements.
• Translate standards, requirements, and policies into terms or processes meaningful to the facility.

• Leadership – serve as a visible, engaged, and dynamic member of the facility leadership team during this assignment.
  • Escalate issues to the Group Director and CEO as indicated.
  • Provides a leadership role in transitioning the Quality program back to the facility upon hire of a permanent Director of Quality through orientation and training.
  • Chairs the monthly Quality Council
  • Complete safety rounds, participate in leadership rou