Director of Quality & Start Up Ops

Overview

PURPOSE STATEMENT:

 

(REMOTE with EXTENSIVE TRAVEL) ( CAN BE BASED ANYWHERE IN US)

 

At the direction of the Group Director, the Director of Quality and Start-Up Operations is a new and expanded role at Acadia Heathcare, who 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 Quality Director is responsible for providing expert guidance and advice on all aspects of policy development; clinical protocol and program implementation; critical incident reporting; regulatory engagement, including development and submission of plans of correction; certification achievement and maintenance; quality assurance and process improvement initiatives; and on-going regulatory readiness strategies in all assigned Acadia facilities. Through routine physical presence, remote data and documentation monitoring, and intentional sharing of deep subject-matter expertise, the Quality Director will ensure a proactive focus on quality and excellence within the assigned facilities and start-up operations.

Responsibilities

 

ESSENTIAL FUNCTIONS:

Monitor the day-to-day regulatory readiness, patient safety, and service excellence in the assigned facilities.

Regulatory preparedness – implement sustainable survey preparation and ongoing monitoring processes, including facility-level auditing and early-issue identification, to maximize achievement of zero- or standard-level survey outcomes.

• Support and teach facility leadership – specifically CEOs, COOs, and Quality and Clinical leadership – to sustainably implement best-practices in regulatory/accreditation compliance as evidenced by measurable results in assigned facilities. Measurements include but are not limited to: survey outcomes, patient safety metrics, patient experience results, HBIPS, etc.
• Develop and maintain proficiency in regulatory planning strategy for all standards for all relevant regulatory and accrediting bodies at the local, state, and federal levels for the assigned facilities and relevant territories.
• Develop corrective action plans for the resolution of areas of regulatory vulnerability or those which could compromise patient safety in collaboration with facility leadership.
• Ensure proper facility reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required.
• Ensure proper facility reporting of incidents and adverse clinical outcomes to duly authorized enforcement agencies or regulatory agencies as appropriate and/or required.
• Initiate and lead communications with regulatory agencies as appropriate.
• Assist in the development of Performance Improvement practices at assigned facilities and maintenance of same including analysis of data and prioritization of efforts to improve survey readiness and consistency of care delivery using expected best-practices.
• Teach facility leadership best-practices in self-monitoring, auditing, and process improvement.
• Ensures effective execution of all activities at assigned facilities concerning the achievement of continuous regulatory and survey readiness. Ensures strategic and operational implementation of regulatory requirements, guidelines, and standards of federal, state, and local licensing agencies, accrediting and certifying organizations.
• Collaborates with Division and Corporate entities and external parties to ensure strategic quality and patient safety initiatives are fully executed at the facility level. Facilitates effective communication with facility and division leadership regarding key clinical performance improvement activities and initiatives.
• Serves as a technical advisor, educator and internal consultant to all hospital management, staff, and physicians on the use of performance improvement tools and techniques, analytical techniques, and statistical applications.

Clinical program fidelity – assess fidelity and identify root-causes for gaps/lapses in fidelity to Acadia standards. Support facility leadership 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 meaning