Director of Quality and Risk Management

Perimeter Healthcare•Garland, TX

12d

About The Position

Perimeter Behavioral Health is one of the leading mental and behavioral healthcare providers in the country. We deliver hope to our patients through comprehensive and dedicated treatment programs. Our focus and commitment to service excellence extends across several states and different care settings. Our team ensures patients receive the high-quality, personalized care they need to overcome mental health and behavioral challenges. We offer a range of settings including inpatient psychiatric hospitals, residential treatment centers, and outpatient counseling and therapies. Join our dedicated nursing team in making a lasting difference in the lives of adolescents and adults facing mental health challenges. As the Director of Quality, Risk, and Compliance, you will oversee the hospital's performance improvement initiatives, risk mitigation strategies, and compliance with state, federal, and accreditation standards. This role plays a vital part in ensuring the delivery of safe, high-quality, and legally compliant healthcare services across the hospital. The Director of Quality/Risk will also ensure TJC/CMS/Texas Code compliance and act as liaison with said entities.

Requirements

Master's degree in a health-related field preferred, or bachelor’s with equivalent experience in psychiatric healthcare; or bachelor's degree in nursing from an accredited school nursing preferred, not required.
Unrestricted Registered Nurse License in the State of Texas or a valid Compact RN License preferred, not required (if applicable).
Previous experience in psychiatric healthcare settings required
CPR and Handle with Care (HWC) training completed within 30 days of hire

Nice To Haves

background in dual diagnosis, substance use, or geriatric care preferred

Responsibilities

Ensure that all staff members deliver care in accordance with the Standards of Care and Practice.
Implement the unit policies and procedures and act as a resource for the staff.
Responsible for unit compliance with Joint Commission, HCFA, state and regulatory standards and patient rights standards.
Evaluate program effectiveness and formulate plans for improvement.
Ensure Safety and Risk Management policies are consistently implemented on the unit.
Process unusual occurrence reports, conduct investigations and corrective plans when needed.
Participates in performance improvement activities and is responsible for the effectiveness of the unit quality improvement program.
Collaborate with case management to ensure patients receive timely quality care.
Participate in the Nurse Staffing Committee meeting to help improve the safety of the hospital and ensure accurate recording and recordkeeping of meeting minutes.
Attend and actively participate in the monthly Nurse Managers meeting.
Report monthly PI and NPS Goals data to the CNO and CEO.
Effectively complete assigned rotation as the Administrator on Call (AOC).
Supervises Patient Advocate/Quality Coordinator, ensures timely resolution of all complaints and grievances.
Adhere to facility, department, corporate and standard policies, and procedures.
Attend all mandatory facility in-services and staff development activities as scheduled.
Adhere to facility standards concerning conduct, dress, attendance, and punctuality.
Support facility-wide quality/performance improvement goals and objectives.
Maintain confidentiality of facility employees and patient information.
Has a broad responsibility to protect the hospital's assets from loss.
The Risk Manager is responsible for coordinating the loss control efforts and advising management and administration on all potential sources of loss and for making recommendations to minimize or eliminate exposure.
Coordinates and conducts Ongoing and Focused Professional Practice Evaluations and Quality of Care Peer Reviews.
Prepares facility for all regulatory surveys; submits corrective action plans for all findings and ensures follow-through on all training/monitoring.
Coordinates and prepares for all committee meetings to include Forms/Policy, Quality, MEC and BOG.
Investigates incidents occurring in the facility and performs Root Cause Analysis when needed.
Reviews of incident reports, patient surveys, patient outcome reports and complaints to determine the presence or absence of patterns and/or opportunities for improvement, as well as appropriateness of corrective action.