Overview

PURPOSE STATEMENT:

The Division Director of Quality is responsible for ensuring patient safety and quality of care as measured by survey readiness, treatment program fidelity, and compliance with state and federal laws and regulations and accreditation standards, including CARF, Joint Commission behavioral health accreditation, and DEA.

Healthcare Experience Required

As such, the Division Director of Quality is responsible for providing expert guidance and advice on all aspects of policy development.

• Substance Abuse/ASAM and Eating Disorders clinical protocol and program implementation (Detox, RTC, PHP/IOP)
• Critical incident reporting; regulatory engagement, including development and submission of plans of correction.
• Certification achievement and maintenance
• Quality assurance and process improvement initiatives; and on-going regulatory readiness strategies to the Division Quality Director to support all assigned Acadia facilities.

Through routine physical presence, remote data and documentation monitoring, and intentional sharing of deep subject-matter expertise, the Division Director of Quality will ensure a proactive focus on quality and safety within the assigned facilities.

ESSENTIAL FUNCTIONS:

• Support and teach facility leadership to sustainably implement best-practices in regulatory/accreditation compliance as evidenced by measurable results in assigned facilities. Measurements include but are not limited to: survey outcomes, patient safety metrics, patient experience results, etc.
• Develop and maintain proficiency in regulatory planning strategy for all standards for all relevant regulatory and accrediting bodies at the local, state, and federal levels for the assigned facilities and relevant territories.
• Develop corrective action plans for the resolution of areas of regulatory vulnerability or those which could compromise patient safety.
• Ensure proper facility reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required.
• Ensure proper facility reporting of incidents and adverse clinical outcomes to duly authorized enforcement agencies or regulatory agencies as appropriate and/or required.
• Initiate and lead communications with regulatory agencies as appropriate.
• Assist in the development of Performance Improvement practices at assigned facilities and maintenance of same including analysis of data and prioritization of efforts to improve survey readiness and consistency of care delivery using expected best-practices.
• Teach facility leadership, including CEOs, COOs, and Quality Directors, best-practices in self-monitoring, auditing, and process improvement.
• Ensures effective execution of all activities concerning the achievement of continuous regulatory and survey readiness. Ensures strategic and operational implementation of regulatory requirements, guidelines, and standards of federal, state, and local licensing agencies, accrediting and certifying organizations.
• Collaborates with Division and Corporate entities and external parties to ensure strategic quality and patient safety initiatives are fully executed at the facility level. Facilitates effective communication with facility and division leadership regarding key clinical performance improvement activities and initiatives.
• Serves as a technical advisor, educator and internal consultant to all facility management, staff, and physicians on the use of performance improvement tools and techniques, analytical techniques, and statistical applications.

• Develop, review, and educate on internal clinical procedures and appropriate use of outcome evaluation tools and the associated results – including patient experience data and other quality scorecard metrics – to ensure continuous quality improvement and ongoing compliance with federal, state, and third-party regulatory requirements.
• Translate standards, requirements, and policies into terms or processes meaningful to the target program.

OTHER FUNCTIONS:

• Performs other duties as assigned.

STANDARD EXPECTATIONS:

• Complies with organizational policies, procedures, performance improvement initiatives and maintains organizational and industry policies regarding confidentiality.
• Communicate clearly and effectively to person(s) receiving services and their family members, guests and other members of the health care team.
• Develops constructive and cooperative working relationships with others and maintains them over time.
• Encourages and builds mutual trust, respect and cooperation among team members.
• Maintains regular and predictable attendance.

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

• Bachelor’s Degree in healthcare or related field required; Master’s degree preferred.
• A minimum of five years’ experience in behavioral healthcare operations at the administrative/leadership level. Previous Medicare/Medicaid Operations/healthcare industry experience preferred.
• Knowledge of the Joint Commission, CMS, CARF, DEA, and relevant local/state standards and regulations.
• Experience in conducting complex, healthcare-focused Root-Cause Analyses and Failure Mode and Effects Analyses.
• Advanced computer skills including Microsoft Office; especially Word, Excel, and PowerPoint.
• Knowledge of office administration procedures with the ability to operate most standard office equipment.
• Ability to work professionally with sensitive, proprietary data & information while maintaining confidentiality.
• Excellent interpersonal skills including the ability to interact effectively and professionally with individuals at all levels; both internal and external.
• Exercises sound judgment in responding to inquiries; understands when to route inquiries to next level.
• Self-motivated with strong organizational skills and superior attention to detail.
• Must be able to manage multiple tasks/projects simultaneously within inflexible time frames. Ability to adapt to frequent priority changes.
• Capable of working within established policies, procedures and practices prescribed by the organization.
• English sufficient to provide and receive instructions/directions.

AHCORP

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