​PURPOSE STATEMENT:  

​Direct the facility Quality Management program which includes oversight of Accreditation and Credentialing Activities.   

​ESSENTIAL FUNCTIONS: 

• ​Monitor and analyze QM data for review by facility management. Submit data to external agencies as required. 
• ​Conduct annual preparation and evaluation of the facility Quality plan. 
• ​Complete QM projects and incorporates the results into patient care improvements. 
• ​ensure facility compliance with policies and applicable standards as required by regulatory/accrediting bodies. 

• ​Submit monthly scorecard data to Acadia corporate office. 
• ​Complete monthly safety rounds and submit 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 Quality Management required. 

• ​Experience in a behavioral health setting preferred. 
• ​Experience with TJC accreditation and regulatory audits preferred. 

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​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. 

We are committed to providing equal  employment opportunities to all applicants for employment regardless of an individual’s characteristics protected by applicable state, federal and local laws.

SWOOD