Assist the Director of Quality in monitoring daytoday regulatory readiness patient safety and service excellence across the facility.
Assist the Director of Quality with QAPI program oversight including assistance with:
Utilizing collected data regarding the outcome of activities for delivering continuously improving services.
Conducting annual preparation and evaluation of the facility QAPI Program.
Completing process improvement projects and incorporate the results into patient care improvements.
Submitting quality scorecard data to Acadia corporate office as requested.
Coordinating the abstraction of clinical data according to Joint Commission specifications and data entry via vendor database for Inpatient Psychiatric Core Measures (HBIPS).
Identifying key aspects of care relevant indicators and evaluation of data using formal and informal feedback from consumers of services and other collateral sources is aggregated and used to improve management strategies and service delivery practices.
Coordinating data collection and analysis from all departments within the facility.
Regulatory preparedness assist the Director of Quality in implementing sustainable survey preparation and ongoing monitoring processes including facilitywide auditing and earlyissue identification to maximize achievement of zero or standardlevel survey outcomes.
Facilitywide support collaborate with other departments to sustainably implement bestpractices in regulatory/accreditation compliance as evidenced by measurable results with regard to survey outcomes patient safety metrics patient experience results HBIPS etc.
Develop and maintain proficiency in the functionality and auditing within electronic platforms such as electronic patient observations and the electronic medical record as applicable.
Engage in and assist with timely and regular evaluation of serious incidents complaints grievances and related investigations.
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
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