Director - Quality and Compliance

3 weeks ago

Lancaster, United States Acadia Healthcare Full time

The Director of Quality/Risk with Performance Improvement will serve the leadership team, patients in system with implementation of facility-wide ongoing quality metrics and efforts to reduce risk to offer a high standard of patient excellence. Rebound Behavioral Health is here to serve those individuals over the age of 18 that are experiencing a behavioral and/or mental health crisis, as well as detox. As the Director of Quality/Risk with Performance Improvement you will shape patient outcomes with opportunities to educate staff.

Functions include but not limited to:

  • Investigate and analyze actual and potential risks in the facility; assess liability and probability of legal action for potential notification. Implement, educate and encourage incident reporting system throughout the facility.
  • Develop and implement infrastructures and systems that support patient safety.
  • Work with internal auditors, security contractors, and other staff to establish an internal control system.
  • Monitor and analyze program performance data to determine program effectiveness and identify opportunities for improvement. Insure compliance with all administrative requirements.
  • Responsible for identifying high-risk areas that could cause harm to persons receiving services, visitors, and employees.
  • Serve as a resource and consultant for risk management activities, performance improvement, policy/procedure development and compliance initiatives.
  • Collaborate with clinical staff and management for prevention of clinical risks throughout the facility. Develops effective working relationships with clinical staff and administrative personnel to facilitate the delivery of patient care.
  • Create and implement policies and procedures that improve both patient care and employee safety. Ensure the application of institutional policies, especially those regarding patient rights, confidentiality and full disclosure.
  • Assess QAPI needs and trends for the facility program by reviewing current practices and gathering, compiling and evaluating data related to employees, services, and patient feedback.
  • Develop written plans to improve and/or correct quality, safety and appropriateness of patient care. Conducts routine evaluations of the effectiveness of services.
  • Develop and implement systems, policies, and procedures for the identification, collection, and analysis of performance measurement data and related information.
  • Conduct timely and regular evaluation of serious incidents, complaints, grievances and related investigations
Educational/Skills/Licensure/Experience 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 a Quality or PI role required.
  • Two or more years' management experience required.
  • Current licensure appropriate for the degree held required.
  • CPR and de-escalation/restraint certification required (training available upon hire and offered by facility)


Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)

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