Director - Quality and Compliance

ESSENTIAL FUNCTIONS:

• Monitors and analyze QM data for review by facility management. Submit data to external agencies as required.
• Conducts annual preparation and evaluation of the facility Quality plan.
• Completes QM projects and incorporates the results into patient care improvements.
• Ensures facility compliance with policies and applicable standards as required by regulatory/accrediting bodies.
• Submits monthly scorecard data to Acadia corporate office.
• Completes monthly safety rounds and submit results/corrective actions to Acadia corporate office
• Reviews incident/safety concerns with the leadership team to identify systemic issues and facilitate the development of       corrective actions.
• Facilitates/oversees investigation and Root Cause Analyses into all serious and/or sentinel events.
• Provides staff management to including hiring, development, training, performance management and communication to     ensure effective and efficient department operation.
• Coordinates the abstraction of clinical data according to Joint Commission specifications and data entry via vendor database for Inpatient Psychiatric Core Measures (HBIPS).

OTHER FUNCTIONS:

• Performs other functions and tasks as assigned.