Director of Quality & Patient Saftey-Recovery

Summit BHC•Raleigh, NC

1d•Onsite

About The Position

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 licensures, 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.

Requirements

Bachelor’s Degree with a clinical, nursing, or business emphasis required. Master’s Degree in Human Services preferred.
Three or more years’ experience in Quality Management, PI role, facility licensure, survey and credentialing process required. Experience in a behavioral health setting preferred.
Experience with TJC and/or CARF accreditation and regulatory audits preferred.
Working knowledge of Regulatory Compliance.
Professional clinical license issued by the appropriate licensing body as required by the state.
CPR and de-escalation certification required (training available upon hire and offered by facility).
First aid may be required based on state or facility.
Two years’ supervisory/management experience required if supervising team members.
Two years’ supervisory/management experience preferred if a standalone position with no supervision responsibilities.

Responsibilities

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 outcome of activities for delivering continuously improving services.
Determines if services meet pre-determined quality improvement expectations and outcomes. Develops written plans to improve and/or correct quality, safety and appropriateness of client care. Conducts routine evaluations of the effectiveness of services.
Ensures correction of any observed deficiencies identified through the quality improvement process
Conducts timely and regular evaluation of serious incidents, complaints, grievances and related investigations.
Provides research, analysis, and consultation on regulatory requirements. Maintains current and updated facility accreditation and regulatory standards manuals.
Ensures proper facility reporting of incidents and adverse clinical outcomes to duly authorized enforcement agencies or regulatory agencies as appropriate and/or required.
May be required to provide onsite coverage for other programs when needed, develops, and executes new programs according to market needs and may provide training, case consultation and Administrator On Call coverage during and after program hours as needed.
Performs Leadership Rounds as assigned to include observation and immediate identification of environment of care, safety, and infection control concerns, as well as real time education of new facility processes.
Develops and implements program policies and procedures that guide the provision of services.
Maintains regular and reliable attendance.
Meets expectations as an exempt employee to work additional hours as required to meet facility needs and project deadlines.
Maintains professionalism and confidentiality of facility employees and patients.
Performs other duties as assigned.