Director-Quality Management

The Director-Quality Management role also includes the following

ESSENTIAL FUNCTIONS:

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

OTHER FUNCTIONS:

• Perform other functions and tasks as assigned.

 EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

• Bachelor’s degree in nursing or human services field required. Master’s degree in nursing or human services preferred. 
• Three or more years’ experience in Quality Management required.
• Experience in a behavioral health setting preferred.
• Experience with TJC accreditation and regulatory audits preferred.

 LICENSES/DESIGNATIONS/CERTIFICATIONS:

• CPR and de-escalation/restraint certification required (training available upon hire and offered by facility).
• First aid may be required based on state or facility.

ADDITIONAL REGULATORY REQUIREMENTS:

As per the facility standards.