Job Description

PURPOSE STATEMENT:

At the direction of the Group Director, the Director of Quality and Start-Up Operations is a new and expanded role at Acadia Heathcare, who 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 Quality Director is responsible for providing expert guidance and advice on all aspects of policy development; clinical protocol and program implementation; 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 in all assigned Acadia facilities. Through routine physical presence, remote data and documentation monitoring, and intentional sharing of deep subject-matter expertise, the Quality Director will ensure a proactive focus on quality and excellence within the assigned facilities and start-up operations.

ESSENTIAL FUNCTIONS:

1. Monitor the day-to-day regulatory readiness, patient safety, and service excellence in the assigned facilities.
2. Regulatory preparedness implement sustainable survey preparation and ongoing monitoring processes, including facility-level auditing and early-issue identification, to maximize achievement of zero- or standard-level survey outcomes.
• Support and teach facility leadership specifically CEOs, COOs, and Quality and Clinical 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, 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 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 in collaboration with facility leadership.
• 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 best-practices in self-monitoring, auditing, and process improvement.
• Ensures effective execution of all activities at assigned facilities 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 hospital management, staff, and physicians on the use of performance improvement tools and techniques, analytical techniques, and statistical applications.
3. Clinical program fidelity assess fidelity and identify root-causes for gaps/lapses in fidelity to Acadia standards. Support facility leadership in developing and implementing remediation and improvement plans to achieve fidelity to Acadias expected practices, including all elements of treatment program implementation.
• 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.
4. Innovation ensure thorough adoption of Acadias selected technology platforms to support patient safety, patient experience, and superior clinical outcomes.
5. Respond to alleged violations of rules, regulations, policies, & Codes of Conduct by evaluating and recommending investigations as appropriate. Coordinate resolution of ethics reports with appropriate members of the Quality team, Compliance team, Human Resources, and/or General Counsel.
6. Maintain regular communication with leadership at assigned facilities regarding clinical, patient safety, patient experience, and regulatory/accreditation issues.
7. Work collaboratively with corporate staff, physicians, Risk management, and other corporate leaders to address performance improvement and safety issues.

1. Serves as the Quality Department lead for assigned growth projects including but not limited to JVs, de novo, mergers and acquisitions and bed expansions.
2. Leads the quality, and regulatory workstreams associated with successful new facility growth for assigned facilities at the direction of the Group Director.
   • This may include evenings, nights or weekends on an as needed basis to help support start-up operations.

1. Collaborates with Operations, Facilities, Nursing and other key stakeholders to facilitate the successful opening of new facilities.
• This includes but is not limited to auditing, monitoring, training, etc..
2. Assists with the orientation and training of staff in collaboration with the facility leadership and other assigned corporate support staff on processes, clinical documentation and regulatory compliance.

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:

• Bachelors Degree in healthcare or related field required; Masters degree preferred.
• A minimum of two years experience in psychiatric healthcare operations. Previous Medicare/Medicaid Operations/healthcare industry experience preferred.
• Knowledge of relevant Joint Commission, CMS, CARF, DEA, and state/local 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. This includes ability to demonstrate proficiency in the electronic medical record.
• 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.

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

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