PURPOSE STATEMENT:

Manage the facility Quality Management program which includes oversight of accreditation and compliance.

ESSENTIAL FUNCTIONS:

· Provide oversight of quality data collection, monitoring, analysis and reporting.

· Monitor and analyze QM data for review by facility management. Submit data to external agencies as required.

· Assist in annual preparation and evaluation of the facility Quality plan.

· Complete QM projects and incorporates the results into patient care improvements.

· Manage facility compliance with policies and applicable standards as required by regulatory/accrediting bodies.

· Submit monthly scorecard data to Acadia corporate office.

· Assist in 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.

· Manage customer satisfaction surveying.

· Collaborate with Risk Management regarding incidents and complaints including investigation, data gathering and data/situational analyses.

· Collaborate with Risk Management to align and implement strategic goals or the facility with corporate and regulatory goals.

· Prepare monthly and quarterly reports as required.

· Maintain complete confidentiality in all patient/program matters in accordance with facility policy.

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.

· Two 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 to providing equal employment opportunities to all applicants for employment regardless of an individual’s characteristics protected by applicable state, federal and local laws.

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