Director of Quality-Recovery

Director of Quality-Recovery | Pacific Sky Recovery Center | Spokane, Washington

About the Job:

The Director of Quality and Performance Improvement is responsible for conducting and implementing work plans, systems, processes and policies designed to ensure compliance with all licensure, insurance, accreditation and certification agencies, federal, and state regulations and laws, and improvement of client safety and quality of care. Directs and monitors the development and implementation of the overall Facility quality assessment and performance improvement process to provide more efficient and streamlined work-flow in the facility. May serve as Chief Health Care Disparities Officer. This position is onsite at the facility and is not a remote position.

Roles and Responsibilities:

ESSENTIAL FUNCTIONS:

· Monitors and directs the day-to-day operations of quality management and compliance process within the organization to establish and maintain a culture of compliance and safety.

· Identifies and prioritizes issues of importance, including those priority issues as set for by leadership. Collaborates with department leaders and corporate leaders, as needed.

· Communicates instructions, expectations and timelines clearly and concisely.

· Continually assesses the facility survey readiness. Functions as survey coordinator during any regulatory survey. In consultation with key managers, prepares responses to survey and addresses recommendations and areas needing improvement.

· Coordinates regulatory activities including licensure, certification and accreditation (OHFLAC, BHHF, CMS, Joint Commission, CARF, ASAM, Office of Civil Rights, etc.). Serves as liaison to the regulatory agencies related to activities within the organization.

· May serve as Chief Health Care Disparity Officer responsible for identifying and analyzing health care disparities for the populations served by the organization and leading activities to reduce those disparities, in coordination with the facility’s Quality Assurance/Performance Improvement Committee (QAPI) and with the oversite by the Medical Executive Committee (MEC) and Governing Board.

· Leads a team of highly engaged members thru hiring, orienting, performance assessment and management, motivating, training, scheduling, and coaching to meet department goals and ensure effective and efficient department operation.

· Maintains productivity levels that are aligned with client census, curtailing unnecessary overtime and/or excessive staff work hours.

· Manages staff scheduling and maintains an updated plan for contingency staffing.

· Maintains accountability expectations for self and staff in all areas of job performance.

· Engages staff in quality and safety basics to ensure sustained, measurable compliance.

· Identifies staff educational needs and ensures they are addressed with education programs that are attended by staff.

· Hold staff accountable for non-compliance and client safety concerns, as well as attendance, following policies, behavior, and adherence to code of conduct.

· Sets expectations, develops plans, and manages processes to measure, assess and improve the quality of clinical programs and/or regulatory/accreditation compliance by measurable results in assigned facilities.

· Develops, reviews, and updates internal clinical procedures, related outcomes measurement, client satisfaction, clinical/financial scorecards to ensure ongoing compliance with federal, state and other third party regulatory requirements and improvement of services.

· Responds to alleged violations of rules, regulations, and policies, by evaluating and recommending investigations as appropriate. Coordinates resolution of ethics reports with appropriate staff/department.

· Maintains proficiency in regulatory planning strategy and the submission of regulatory plans. Develops corrective action plans for the resolution of problematic issues or to address areas of compliance vulnerability.

· Collects and provides data for compliance requests, dashboards, and scorecards. Prepares and submits accurate and comprehensive reports as required both internally and externally.

· Oversees the coordination of internal and external governmental compliance/privacy investigations or reimbursement reviews at the facility to ensure investigations/reviews are conducted appropriately and that responses to external entities are consistent with facility standards and expectations.

· Provides a broad vision in the strategic development and direction of the performance improvement program for the facility. Develops a facility-wide performance improvement plan and PI tools.

· Develops processes for identification, collection and analysis of performance measurement data. Utilizes collected data regarding the ou