Director of Quality and Performance Improvement

Overview

Riverwoods Behavioral Health System is looking for an experienced Director of Quality & Accreditation to join our team!

Riverwoods Behavioral Health System is located in Riverdale, Georgia, which is part of the Atlanta metropolitan area. The facility is a respected provider of comprehensive programming for adolescents, adults, and seniors of all genders who are struggling with mental health concerns and substance use disorders. Treatment at Riverwoods Behavioral Health System may include detoxification, inpatient care, and outpatient services. We are seeking a Director of Quality and Accreditation to join our team.

• $5,000 Sign on Bonus Offered

• Lead and monitor day-to-day regulatory readiness, patient safety, and service excellence across the facility.
• QAPI program oversight and management – follow and develop processes for identification, collection, and analysis of quality performance data.
• Utilize collected data regarding the outcome of activities for delivering continuously improving services.
• Conduct annual preparation and evaluation of the facility QAPI Program.
• Complete process improvement projects and incorporate the results into patient care improvements.
• Submit quality scorecard data to Acadia corporate office as requested.
• Coordinate the abstraction of clinical data according to Joint Commission specifications and data entry via vendor database for Inpatient Psychiatric Core Measures (e.g., HBIPS).
• Identify key aspects of care relevant indicators and evaluation of data using formal and informal feedback from consumers of services and other collateral sources; aggregate and use to improve management strategies and service delivery practices.
• Lead/coordinate data collection and analysis from all departments within the facility.
• Prepare and present program data trends and action plans to the monthly Quality Council and quarterly to the Medical Executive Committee and the Governing Board.

• Regulatory preparedness – implement sustainable survey preparation and ongoing monitoring processes, including facility-wide auditing and early-issue identification, to maximize achievement of zero- or standard-level survey outcomes.
• Facility-wide support – collaborate with other departments to sustainably implement best-practices in regulatory/accreditation compliance as evidenced by measurable results with regard to survey outcomes, patient safety metrics, patient experience results, HBIPS, 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 level.
• Develop and maintain proficiency in the functionality and auditing within electronic platforms such as electronic patient observations and the electronic medical record, as applicable.
• Lead Root-Cause Analyses and conduct timely and regular evaluation of serious incidents, complaints, grievances and related investigations to:
  • Identification of events, trends and patterns that may affect client health, safety and or treatment efficacy
  • Committee evaluation findings and recommendations submitted to agency management for corrective action
  • Implemented actions, outcomes, trends analyzed over time
• Develop corrective action plans for the resolution of areas of regulatory vulnerability or those which could compromise patient safety in collaboration with other facility leaders.
• Ensure proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required.
• Ensure proper reporting of incidents and adverse clinical outcomes to duly authorized enforcement agencies or regulatory agencies as appropriate and/or required.
• In conjunction with assigned corporate Division Quality Director, initiate and lead communications with regulatory agencies as appropriate.
• Develop sustainable performance improvement practices through analysis of data and prioritization of efforts to improve survey readiness and consistency of care delivery using expected best-practices.
• Ensure multidisciplinary ownership of best-practices in self-monitoring, auditing, and process…