Director Of Quality Management

? PURPOSE STATEMENT: ? Direct the facility Quality Management program which includes oversight of Accreditation and Credentialing Activities.  
? ESSENTIAL FUNCTIONS: ? Monitor and analyz e QM data for review by facility management. Submit data to external agencies as required .  ? Conduct a nnual preparation an d evaluation of the facility Quality plan.  ? Complet e QM projects and incorporates the results into patient care improvements .  ? ensure facility c ompliance with policies and applicable standards as required by regulatory/accrediting bodies.  ? Submit monthly scorecard data to Acadia corporate office.  ? Complet e monthly safety rounds and submi t 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 Nursing or Human Services field required . Master's Degree in Nursing or Human Services preferred .  ? Three or more years' experience in Q uality 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.   AHMKT
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