Our programming offers innovative behavioral health and psychiatric therapies for children and adolescents ages 3-21 whose lives have been disrupted by mental illness. 

Southwood is seeking a dedicated and detail-oriented Quality Coordinator to join our team and play a key role in ensuring the highest standards of patient care and safety. This position is responsible in assisting in overseeing regulatory compliance, operational quality, and continuous improvement across the facility. The Quality Coordinator will collaborate with leadership (Director of Quality)  to maintain survey readiness, implement process improvements, and engage in proactive monitoring of clinical data and incidents. If you have a passion for quality healthcare and a strong commitment to patient safety, we invite you to apply and contribute to our mission of excellence in care.

PURPOSE STATEMENT:

The Quality Coordinator is responsible for ensuring patient safety and superior quality of care as measured by survey readiness, treatment program fidelity, and compliance with state and federal laws and regulations and accreditation standards. As such, the Coordinator is responsible for overseeing all aspects of policy and procedure implementation; operational quality oversight standards, and programmatic expectations; critical incident reporting; regulatory engagement, including development and submission of plans of correction; certification achievement and maintenance; oversight of the quality assurance and process improvement (QAPI) program; and on-going regulatory readiness strategies at the facility. Through routine physical presence in patient care areas, data review and documentation monitoring, and intentional sharing of subject-matter expertise, the Coordinator will ensure a proactive, multidisciplinary focus on quality and excellence within the facility.

ESSENTIAL FUNCTIONS:

• Assist the Director of Quality in monitoring day-to-day regulatory readiness, patient safety, and service excellence across the facility.
• Assist the Director of Quality with QAPI program oversight, including assistance with:
  • Utilizing collected data regarding the outcome of activities for delivering continuously improving services.
  • Conducting annual preparation and evaluation of the facility QAPI Program.
  • Completing process improvement projects and incorporate the results into patient care improvements.
  • Submitting quality scorecard data to Acadia corporate office as requested.
  • Coordinating the abstraction of clinical data according to Joint Commission specifications and data entry via vendor database for Inpatient Psychiatric Core Measures (HBIPS).
  • Identifying key aspects of care relevant indicators and evaluation of data using formal and informal feedback from consumers of services and other collateral sources is aggregated and used to improve management strategies and service delivery practices.
  • Coordinating data collection and analysis from all departments within the facility.
  • Preparing program data trends and action plans for the monthly Quality Council and quarterly to the Medical Executive Committee and the Governing Board.
• Regulatory preparedness – assist the Director of Quality in implementing 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 the functionality and auditing within electronic platforms such as electronic patient observations and the electronic medical record, as applicable.
  • Engage in and assist with timely and regular evaluation of serious incidents, complaints, grievances and related investigations.
  • 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.
  • Assist with proper reporting of incidents and adverse clinical outcomes to duly authorized enforcement agencies or regulatory agencies as appropriate and/or required.
  • Propose 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.
  • Under direction of the Quality Director, ensure multidisciplinary ownership of best-practices in self-monitoring, auditing, and process improvement, escalating opportunities for improved engagement to the Quality Director as appropriate.
  • Ensures operational implementation of regulatory requirements, guidelines, and standards of federal, state, and local licensing agencies, accrediting and certifying organizations.
  • Serves as a technical advisor, educator and internal consultant to all hospital management, staff, and physicians on the use of performance improvement tools and techniques, analytical techniques, and statistical applications.
  • Ensure facility compliance with policies and applicable standards as required by regulatory/accrediting bodies.

• Role Model – serve as a visible, engaged, and dynamic member of the facility team.
  • Review incident/safety concerns with the Quality Director and select members of the leadership team to identify systemic issues and facilitate the development of corrective actions.
  • Identification of problems or potential problems to prevent risks to patients and staff.
  • Proposes corrective steps that may include, but are not limited to:
  • Changes in policies/procedures,
  • Staffing and assignment changes,
  • Additional education or training for staff,
  • Addition or deletion of services

OTHER FUNCTIONS:

• Perform other functions and tasks as assigned.

SWOOD

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

• Bachelor’s Degree in Human Services or nursing required, Master’s degree preferred.
• One or more years of experience in a Quality or PI role preferred.
• One or more years of management experience preferred.
• Experience with CARF, DEA, Joint Commission, or CMS surveys, as required by service line(s) supported

LICENSES/DESIGNATIONS/CERTIFICATIONS:

• Current licensure appropriate for the degree held required.
• 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.

ADDITIONAL REGULATORY REQUIREMENTS:

While this job description is intended to be an accurate reflection of the requirements of the job, management reserves the right to add or remove duties from particular jobs when circumstances (e.g. emergencies, changes in workload, rush jobs or technological developments) dictate.