Director of Quality Management

PURPOSE STATEMENT:

Direct the facility Quality Management program which includes oversight of Accreditation and Credentialing Activities.

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 Human Services or nursing required. Master's degree in behavioral health/risk discipline, Registered Nurse 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.

We are committed toprovidingequalemploymentopportunitiestoall applicantsforemploymentregardlessofanindividual'scharacteristicsprotected byapplicable state,federalandlocallaws.

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