Coachella Valley Behavioral Health
Director of Quality and PI
Coachella Valley Behavioral Health, Indio, California, United States, 92201
Director of Quality and PI
Join to apply for the Director of Quality and PI role at Coachella Valley Behavioral Health. Located in Indio, California, Coachella Valley Behavioral Health is the only facility of its kind in the area, and we are proud to provide services for those in need of clinically excellent behavioral healthcare.
Our 80‑bed facility offers inpatient programming for adults age 18+ who have mental health concerns and addictions. We believe that the most effective mental health and addiction treatment involves treating the whole person, accounting for the physical, social, and emotional factors that can affect a person’s well‑being.
Compensation:
$108,000 – $135,000
Purpose Statement The Director of Quality and Accreditation 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. The Director leads and oversees all aspects of policy development, comprehensive implementation of clinical protocols, operational quality oversight standards, critical incident reporting, regulatory engagement, certification achievement and maintenance, and the QAPI program.
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 to deliver continuously improving services.
Conduct annual preparation and evaluation of the facility QAPI Program.
Complete process improvement projects and incorporate results into patient care improvements.
Submit quality scorecard data to Acadia corporate office as requested.
Coordinate abstraction of clinical data according to Joint Commission specifications.
Identify key indicators and evaluate data using formal and informal feedback from consumers and other sources.
Lead/coordinate data collection and analysis from all departments.
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.
Collaborate with other departments to implement best‑practices in regulatory and accreditation compliance.
Develop and maintain proficiency in regulatory planning strategy for all relevant bodies.
Lead root‑cause analyses and conduct regular evaluations of serious incidents, complaints, and grievances.
Develop corrective action plans for regulatory vulnerability areas.
Ensure proper reporting of violations or potential violations to enforcement agencies.
Initiate and lead communications with regulatory agencies as appropriate.
Develop sustainable performance improvement practices through data analysis.
Ensure multidisciplinary ownership of best‑practices in self‑monitoring, auditing, and process improvement.
Serve as technical advisor, educator and internal consultant to all hospital staff and physicians.
Ensure compliance with policies and applicable standards required by regulatory bodies.
Act as a subject‑matter expert on high‑reliability principles and strategies to achieve zero harm.
Support other departments in developing and implementing remediation and improvement plans to achieve fidelity to Acadia’s expected practices.
Translate standards, requirements, and policies into meaningful terms or processes for the facility.
Leadership – serve as a visible, engaged, and dynamic member of the facility leadership team.
Chair 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 development of corrective actions.
Lead and facilitate root‑cause analyses into serious and/or sentinel events.
Invest in staff through engagement in hiring, development, training, performance management, and communication.
Oversee the Culture of Safety Survey and follow‑up action planning and sustainment processes.
Identify problems or potential problems to prevent risks to patients and staff and propose corrective steps.
Perform other functions and tasks as assigned.
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 (e.g., emergencies, changes in workload, rush jobs or technological developments) 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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Our 80‑bed facility offers inpatient programming for adults age 18+ who have mental health concerns and addictions. We believe that the most effective mental health and addiction treatment involves treating the whole person, accounting for the physical, social, and emotional factors that can affect a person’s well‑being.
Compensation:
$108,000 – $135,000
Purpose Statement The Director of Quality and Accreditation 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. The Director leads and oversees all aspects of policy development, comprehensive implementation of clinical protocols, operational quality oversight standards, critical incident reporting, regulatory engagement, certification achievement and maintenance, and the QAPI program.
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 to deliver continuously improving services.
Conduct annual preparation and evaluation of the facility QAPI Program.
Complete process improvement projects and incorporate results into patient care improvements.
Submit quality scorecard data to Acadia corporate office as requested.
Coordinate abstraction of clinical data according to Joint Commission specifications.
Identify key indicators and evaluate data using formal and informal feedback from consumers and other sources.
Lead/coordinate data collection and analysis from all departments.
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.
Collaborate with other departments to implement best‑practices in regulatory and accreditation compliance.
Develop and maintain proficiency in regulatory planning strategy for all relevant bodies.
Lead root‑cause analyses and conduct regular evaluations of serious incidents, complaints, and grievances.
Develop corrective action plans for regulatory vulnerability areas.
Ensure proper reporting of violations or potential violations to enforcement agencies.
Initiate and lead communications with regulatory agencies as appropriate.
Develop sustainable performance improvement practices through data analysis.
Ensure multidisciplinary ownership of best‑practices in self‑monitoring, auditing, and process improvement.
Serve as technical advisor, educator and internal consultant to all hospital staff and physicians.
Ensure compliance with policies and applicable standards required by regulatory bodies.
Act as a subject‑matter expert on high‑reliability principles and strategies to achieve zero harm.
Support other departments in developing and implementing remediation and improvement plans to achieve fidelity to Acadia’s expected practices.
Translate standards, requirements, and policies into meaningful terms or processes for the facility.
Leadership – serve as a visible, engaged, and dynamic member of the facility leadership team.
Chair 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 development of corrective actions.
Lead and facilitate root‑cause analyses into serious and/or sentinel events.
Invest in staff through engagement in hiring, development, training, performance management, and communication.
Oversee the Culture of Safety Survey and follow‑up action planning and sustainment processes.
Identify problems or potential problems to prevent risks to patients and staff and propose corrective steps.
Perform other functions and tasks as assigned.
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 (e.g., emergencies, changes in workload, rush jobs or technological developments) 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.
#J-18808-Ljbffr