Acadia Healthcare
Overview
Director of Quality Montrose Behavioral Health Hospital At Montrose Behavioral Health Hospital, our goal is to provide personalized treatment for those who are suffering from mental health disorders and co-occurring addictions. We are seeking a Director of Quality to lead our team. To learn more visit: Chicago's Preferred Acute Psych Hospital | Montrose Behavioral Health Responsibilities
ESSENTIAL FUNCTIONS: 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., national quality measures such as 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 with measurable results on survey outcomes, patient safety metrics, and patient experience results. Develop and maintain proficiency in regulatory planning strategy for all relevant standards for all regulatory and accrediting bodies at local, state, and federal levels. 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 identify events, trends and patterns that may affect client health, safety and treatment efficacy; submit committee evaluation findings and recommendations for corrective action; implement actions and track outcomes. 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 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 data analysis and prioritization of efforts to improve survey readiness and consistency of care delivery using best practices. Ensure multidisciplinary ownership of best practices in self-monitoring, auditing, and process improvement, escalating opportunities for improved engagement to the facility CEO as appropriate. Ensure 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. Ensure facility compliance with policies and applicable standards as required by regulatory/accrediting bodies. Facility leader and subject matter expert on high reliability principles and strategies to achieve zero harm. Clinical program excellence — assess fidelity and identify root-causes for gaps in fidelity to standards. Support other departments in developing and implementing remediation and improvement plans to achieve fidelity to 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 facility. Leadership — serve as a visible, engaged, and dynamic member of the facility leadership team. Chairs the monthly Quality Council Complete safety rounds, participate in leadership rounding, 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. Lead and facilitate Root Cause Analyses into all serious and/or sentinel events. Invest in the facility staff through engagement in hiring, development, training, performance management, and communication to ensure effective and efficient operations. Oversees the Culture of Safety Survey and follow-up action planning and sustainment processes. Identification of problems or potential problems to prevent risks to patients and staff, proposing corrective steps that may include but are not limited to: changes in policies/procedures, staffing and assignment changes, additional education or training for staff, or addition/removal of services. Other functions: Perform other functions and tasks as assigned. Qualifications
Education/Experience/Skill Requirements: Bachelor’s Degree in Human Services or nursing required. Master’s degree in behavioral health/risk discipline; Registered Nurse preferred. Two or more years of experience in a Quality, Clinical, or PI role required. 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 dictate. 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.
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Director of Quality Montrose Behavioral Health Hospital At Montrose Behavioral Health Hospital, our goal is to provide personalized treatment for those who are suffering from mental health disorders and co-occurring addictions. We are seeking a Director of Quality to lead our team. To learn more visit: Chicago's Preferred Acute Psych Hospital | Montrose Behavioral Health Responsibilities
ESSENTIAL FUNCTIONS: 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., national quality measures such as 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 with measurable results on survey outcomes, patient safety metrics, and patient experience results. Develop and maintain proficiency in regulatory planning strategy for all relevant standards for all regulatory and accrediting bodies at local, state, and federal levels. 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 identify events, trends and patterns that may affect client health, safety and treatment efficacy; submit committee evaluation findings and recommendations for corrective action; implement actions and track outcomes. 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 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 data analysis and prioritization of efforts to improve survey readiness and consistency of care delivery using best practices. Ensure multidisciplinary ownership of best practices in self-monitoring, auditing, and process improvement, escalating opportunities for improved engagement to the facility CEO as appropriate. Ensure 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. Ensure facility compliance with policies and applicable standards as required by regulatory/accrediting bodies. Facility leader and subject matter expert on high reliability principles and strategies to achieve zero harm. Clinical program excellence — assess fidelity and identify root-causes for gaps in fidelity to standards. Support other departments in developing and implementing remediation and improvement plans to achieve fidelity to 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 facility. Leadership — serve as a visible, engaged, and dynamic member of the facility leadership team. Chairs the monthly Quality Council Complete safety rounds, participate in leadership rounding, 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. Lead and facilitate Root Cause Analyses into all serious and/or sentinel events. Invest in the facility staff through engagement in hiring, development, training, performance management, and communication to ensure effective and efficient operations. Oversees the Culture of Safety Survey and follow-up action planning and sustainment processes. Identification of problems or potential problems to prevent risks to patients and staff, proposing corrective steps that may include but are not limited to: changes in policies/procedures, staffing and assignment changes, additional education or training for staff, or addition/removal of services. Other functions: Perform other functions and tasks as assigned. Qualifications
Education/Experience/Skill Requirements: Bachelor’s Degree in Human Services or nursing required. Master’s degree in behavioral health/risk discipline; Registered Nurse preferred. Two or more years of experience in a Quality, Clinical, or PI role required. 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 dictate. 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.
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