Acadia Healthcare
Director, Quality and Startup Operations
Acadia Healthcare, Franklin, Tennessee, us, 37068
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 Healthcare, 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 Quality Director provides 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 ongoing regulatory readiness strategies in all assigned Acadia facilities.
ESSENTIAL FUNCTIONS:
Monitor the day-to-day regulatory readiness, patient safety, and service excellence in the assigned facilities.
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 to sustainably implement best practices in regulatory/accreditation compliance as evidenced by measurable results in assigned facilities.
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.
Develop corrective action plans for 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.
Initiate and lead communications with regulatory agencies as appropriate.
Assist in the development of Performance Improvement practices at assigned facilities including analysis of data and prioritization of efforts to improve survey readiness.
Teach facility leadership best practices in self-monitoring, auditing, and process improvement.
Ensure effective execution of all activities at assigned facilities concerning the achievement of continuous regulatory and survey readiness.
Collaborate with Division and Corporate entities and external parties to ensure strategic quality and patient safety initiatives are fully executed at the facility level.
Serve as a technical advisor, educator, and internal consultant to all hospital management, staff, and physicians on the use of performance improvement tools and techniques.
Assess fidelity and identify root-causes for gaps/lapses in fidelity to Acadia standards.
Develop, review, and educate on internal clinical procedures and appropriate use of outcome evaluation tools.
Ensure thorough adoption of Acadia’s selected technology platforms to support patient safety, patient experience, and superior clinical outcomes.
Respond to alleged violations of rules, regulations, policies, & Codes of Conduct by evaluating and recommending investigations as appropriate.
Maintain regular communication with leadership at assigned facilities regarding clinical, patient safety, and regulatory/accreditation issues.
Work collaboratively with corporate staff, physicians, Risk management, and other corporate leaders to address performance improvement and safety issues.
Serve as the Quality Department lead for assigned growth projects including JVs, de novo, mergers and acquisitions, and bed expansions.
Lead the quality and regulatory workstreams associated with successful new facility growth.
Collaborate with Operations, Facilities, Nursing, and other key stakeholders to facilitate the successful opening of new facilities.
Assist with the orientation and training of staff in collaboration with facility leadership and other assigned corporate support staff.
Perform other duties as assigned.
STANDARD EXPECTATIONS:
Comply with organizational policies, procedures, and performance improvement initiatives.
Communicate clearly and effectively to person(s) receiving services and their family members.
Develop constructive and cooperative working relationships with others.
Encourage and build mutual trust, respect, and cooperation among team members.
Maintain regular and predictable attendance.
EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:
Bachelor’s Degree in healthcare or related field required; Master’s degree preferred.
A minimum of two years experience in psychiatric healthcare operations.
Knowledge of relevant Joint Commission, CMS, CARF, DEA, and state/local standards and regulations.
Experience in conducting complex, healthcare-focused Root-Cause Analyses.
Advanced computer skills including Microsoft Office.
Knowledge of office administration procedures.
Ability to work professionally with sensitive data while maintaining confidentiality.
Excellent interpersonal skills.
Self-motivated with strong organizational skills.
Capable of managing multiple tasks/projects simultaneously.
English sufficient to provide and receive instructions/directions.
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.
AHCORP
#LI-JR1
#J-18808-Ljbffr
At the direction of the Group Director, the Director of Quality and Start-Up Operations is a new and expanded role at Acadia Healthcare, 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 Quality Director provides 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 ongoing regulatory readiness strategies in all assigned Acadia facilities.
ESSENTIAL FUNCTIONS:
Monitor the day-to-day regulatory readiness, patient safety, and service excellence in the assigned facilities.
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 to sustainably implement best practices in regulatory/accreditation compliance as evidenced by measurable results in assigned facilities.
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.
Develop corrective action plans for 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.
Initiate and lead communications with regulatory agencies as appropriate.
Assist in the development of Performance Improvement practices at assigned facilities including analysis of data and prioritization of efforts to improve survey readiness.
Teach facility leadership best practices in self-monitoring, auditing, and process improvement.
Ensure effective execution of all activities at assigned facilities concerning the achievement of continuous regulatory and survey readiness.
Collaborate with Division and Corporate entities and external parties to ensure strategic quality and patient safety initiatives are fully executed at the facility level.
Serve as a technical advisor, educator, and internal consultant to all hospital management, staff, and physicians on the use of performance improvement tools and techniques.
Assess fidelity and identify root-causes for gaps/lapses in fidelity to Acadia standards.
Develop, review, and educate on internal clinical procedures and appropriate use of outcome evaluation tools.
Ensure thorough adoption of Acadia’s selected technology platforms to support patient safety, patient experience, and superior clinical outcomes.
Respond to alleged violations of rules, regulations, policies, & Codes of Conduct by evaluating and recommending investigations as appropriate.
Maintain regular communication with leadership at assigned facilities regarding clinical, patient safety, and regulatory/accreditation issues.
Work collaboratively with corporate staff, physicians, Risk management, and other corporate leaders to address performance improvement and safety issues.
Serve as the Quality Department lead for assigned growth projects including JVs, de novo, mergers and acquisitions, and bed expansions.
Lead the quality and regulatory workstreams associated with successful new facility growth.
Collaborate with Operations, Facilities, Nursing, and other key stakeholders to facilitate the successful opening of new facilities.
Assist with the orientation and training of staff in collaboration with facility leadership and other assigned corporate support staff.
Perform other duties as assigned.
STANDARD EXPECTATIONS:
Comply with organizational policies, procedures, and performance improvement initiatives.
Communicate clearly and effectively to person(s) receiving services and their family members.
Develop constructive and cooperative working relationships with others.
Encourage and build mutual trust, respect, and cooperation among team members.
Maintain regular and predictable attendance.
EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:
Bachelor’s Degree in healthcare or related field required; Master’s degree preferred.
A minimum of two years experience in psychiatric healthcare operations.
Knowledge of relevant Joint Commission, CMS, CARF, DEA, and state/local standards and regulations.
Experience in conducting complex, healthcare-focused Root-Cause Analyses.
Advanced computer skills including Microsoft Office.
Knowledge of office administration procedures.
Ability to work professionally with sensitive data while maintaining confidentiality.
Excellent interpersonal skills.
Self-motivated with strong organizational skills.
Capable of managing multiple tasks/projects simultaneously.
English sufficient to provide and receive instructions/directions.
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.
AHCORP
#LI-JR1
#J-18808-Ljbffr