Resource Director of Quality - Behavioral Health

ESSENTIAL FUNCTIONS:

• Identifies, evaluates, and prioritizes key areas related to quality, risk management, and patient safety within the facility while serving as the Interim Director of Quality and Patient Safety for the facility.
• Protects sensitive information by ensuring all quality and risk management activities comply with confidentiality and privacy regulations.
• Oversees the facility’s incident reporting system, ensuring proper classification, documentation, and timely closure of incidents.
• Conducts trend analyses for adverse events, near misses, and sentinel events.
• Initiates prompt investigations of significant events or allegations, including evaluating safety interventions, reviewing documentation, conducting interviews, and documenting findings.
• Develops and implements strategies to mitigate risk and prevent recurrence of adverse events.
• Ensures timely notifications of significant events to the facility CEO, corporate leadership, state authorities/agencies, and accrediting bodies as required.
• Collaborates with corporate legal, risk management, and compliance to manage high-risk or legal situations.
• Responsible for the coordination and reporting of patient safety events/risks and compliance program in conjunction with the facility’s Quality Assurance/Performance Improvement Committee (QAPI) with the oversite by the Medical Executive Committee (MEC) and Governing Board with the authority to intervene in situations which may pose an immediate threat to life, safety, risk, performance improvement, and compliance.
• Responsible for identifying and analyzing health care disparities for the populations served by the organization and leading activities to reduce those disparities, in coordination with the facility’s Quality Assurance/Performance Improvement Committee (QAPI) and with the oversite by the Medical Executive Committee (MEC) and Governing Board.
• Apply state, federal, and accreditation licensing and reporting requirements for the facility
• Ensures all programs adhere to applicable standards, including Joint Commission and CARF, as well as state and federal regulations.
• Serves as a survey liaison during visits from external auditors or regulatory agencies.
• Works with department leaders to implement corrective action plans to address deficiencies identified through risk analyses, self-identification, external audits, mock surveys, or onsite corporate reviews.
• Facilitates root cause analyses (RCAs), event analysis, failure mode and effects analyses (FMEAs), and other process evaluations as needed.
• Conducts regular leadership meetings to review performance improvement initiatives, monitor corrective action plans, and track supporting evidence.
• Responsible for the development and implementation of an annual QAPI Plan, including a yearly review to ensure its effectiveness, relevance, and alignment with the facility’s goals.
• Leads the facility’s quality improvement program, directs initiatives, monitors key performance indicators (KPIs), and analyzes data trends to enhance overall quality, organizational performance, and improve patient safety.
• Provide guidance and support to leadership and staff on quality, risk, and safety initiatives.
• Completes required documentation and reports such as Weekly Risk Report, Facility Smart Sheets, and other documents as requested.
• Regularly reviews medical records to ensure compliance with documentation standards.
• Attends and participates in scheduled calls and meetings.
• Responsible for completing tasks as assigned.

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

• Bachelor’s degree in nursing, behavioral health or related field required. Masters’ Degree (MPH, MSN, MHA, MSW or related) preferred.
• Three or more years’ experience in healthcare quality, patient safety, or risk management.
• Experience in behavioral health setting and multi-site operations required.
• Deep knowledge of QAPI frameworks (e.g. PDCA).
• Familiarity with behavioral health accreditation and regulatory requirements.
• Strong data analysis skills including proficiency with quality software/tools, Excel, Power BI, HC analytics.
• Ability to travel by air and car up to 80% of the time.

LICENSES/DESIGNATIONS/CERTIFICATIONS:

Certified Professional in Healthcare Quality (CPHQ) or Patient Safety (CPPS) preferred.

SUPERVISORY REQUIREMENTS:

Three or more years of progressive leadership experience in behavioral health.

 WORK LOCATION:

This position is remote.