Director-Quality & Performance Improvement

Acadia External•Belton, TX

About The Position

Situated on over 30 acres in the beautiful rolling hills of Central Texas, Cedar Crest provides innovative behavioral health and substance abuse treatment for children, adolescents, and adults. Our private campus includes walking trails, picnic areas, outdoor swimming pool, full-size gym, and state-of-the-art exercise equipment, providing opportunities for leisure, therapeutic recreation, and team building skills. Cedar Crest provides a full continuum of care including adolescent residential, inpatient, outpatient, and partial hospitalization/intense outpatient treatments. PURPOSE STATEMENT: Develop and implement a planned, systematic and on-going system for monitoring and improving quality, safety and appropriateness of patient care. ESSENTIAL FUNCTIONS: Develop processes for identification, collection and analysis of performance measurement data. Utilize collected data regarding the outcome of activities for delivering continuously improving services. Develop written plans to improve and/or correct quality, safety and appropriateness of patient care. Conducts routine evaluations of the effectiveness of services. Develop and implement systems, policies, and procedures for the identification, collection, and analysis of performance measurement data and related information. Determine if services meet pre-determined quality improvement expectations and outcomes. Ensure correction of any observed deficiencies identified through the quality improvement process. Identify 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. Conduct timely and regular evaluation of serious incidents, complaints, grievances and related investigations to: Identification of events, trends and patterns that may affect client health, safety and or treatment efficacy Committee evaluation findings and recommendations submitted to agency management for corrective action Implemented actions, outcomes, trends analyzed over time Identification of problems or potential problems to. prevent risks to patients. Proposes corrective steps that may include, but are not limited to: Changes in policies/procedures Staffing and assignment changes Additional education or training for staff Addition or deletion of services OTHER FUNCTIONS: Perform other functions and tasks as assigned.

Requirements

Bachelor’s degree in human services or nursing required.
Three or more years’ experience in a Quality or PI role required.
Two or more years’ management experience required.
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.

Nice To Haves

Master’s degree in behavioral health/risk discipline, Registered Nurse preferred.

Responsibilities

Develop processes for identification, collection and analysis of performance measurement data.
Utilize collected data regarding the outcome of activities for delivering continuously improving services.
Develop written plans to improve and/or correct quality, safety and appropriateness of patient care.
Conducts routine evaluations of the effectiveness of services.
Develop and implement systems, policies, and procedures for the identification, collection, and analysis of performance measurement data and related information.
Determine if services meet pre-determined quality improvement expectations and outcomes.
Ensure correction of any observed deficiencies identified through the quality improvement process.
Identify 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.
Conduct timely and regular evaluation of serious incidents, complaints, grievances and related investigations to: Identification of events, trends and patterns that may affect client health, safety and or treatment efficacy Committee evaluation findings and recommendations submitted to agency management for corrective action Implemented actions, outcomes, trends analyzed over time Identification of problems or potential problems to. prevent risks to patients.
Proposes corrective steps that may include, but are not limited to: Changes in policies/procedures Staffing and assignment changes Additional education or training for staff Addition or deletion of services
Perform other functions and tasks as assigned.