Director-Quality Management

· 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).