Director of Regulatory & Quality Improvement - Auburn Hills, MI

Company: Hire Velocity
Location: Auburn Hills
Posted on: August 7, 2022

Job Description:

Psychiatric-Mental Health opening in Auburn Hills, Michigan. This and other rn jobs brought to you by NursingJobCafe.com

Joint Commission-accredited and licensed psychiatric hospital, overlooking Lake Galloway in Auburn Hills, Michigan. We specialize in providing comprehensive, compassionate behavioral health services to children, adolescents and adults. It is the ultimate goal of our dedicated staff to build strength, confidence and knowledge within each patient, in hopes that they may continue learning and understanding their needs and practicing self-care for the rest of their lives.




POSITION SUMMARY:

The Director of Regulatory and Quality is responsible for the development, implementation, coordination, and aggregation of the hospital wide Performance Improvement Plan. Additionally, the individual is responsible to develop, implement and oversee all regulatory compliance activities to ensure compliance with all The Joint Commission, CMMS and State standards, rules and conditions of participation.




Duties include but are not limited to:

Collects, coordinates and maintains informational reports from all departments and committees as outlined in the Performance Improvement (PI) Plan.
Provides expertise in responding to quality requirements of external agencies, i.e. The Joint Commission. CMMS, etc.
Coordinates and monitors the hospital wide PI Plan in order to maintain compliance with The Joint Commission, CMMS, and other regulatory agencies.
Evaluates and improves the systems, forms, procedures, methods, and motions used in accomplishing all PI work.
Assists Medical Staff in evaluating the quality of patient care and in developing criteria and methods for such evaluation.
Provides ongoing communication, resources, education, and aggregated data/information to all department managers, related to issues involving quality, safety, and survey readiness.
Assist with annual evaluation (and revision if necessary) of the PI Plan.
Plans, develops, and presents in-services relevant to PI and survey readiness as necessary.
Responsible for the review, development, and implementation of the department policies and procedures.
Serves as a liaison between the medical staff, or committees and the Health Information Management Department.
Serves as the facility's Compliance Officer.
Ensures the hospital's environment is safe, clean, and well organized. Makes recommendations for resources and adequate space. Submits requests for repairs and for required equipment. Conducts quarterly safety rounds.
Maintains knowledge and understanding of The Joint Commission (CAMH, CAMBH) and CMMS Standards and strategies for compliance. Acts as the facility liaison during the survey process including other applicable state and federal regulatory agencies. Ensures timely response and oversees development and implementation of any required corrective actions. Assigns tasks as necessary to other departmental managers to assist in overall regulatory compliance.
Reviews and analyzes root causes, patterns, or trends in data collection and informs applicable Facility management staff; helps to identify and implement corrective action and performance improvement processes.
Provides continuous support in the analysis of performance improvement initiatives and re-establishing requirements which will facilitate continuous improvement. Fosters the development and tracking of performance indicators at the departmental level; encourages a facility-wide team effort in meeting performance improvement goals.
Assures that hiring, disciplinary actions and termination procedures are conducted in accordance with hospital policies.




Qualifications

Bachelor's degree in Human or Health Services field required. MSN or advanced degree preferred.
Valid licensure in the State of Michigan as a RN, NP, MSW, MA, PhD in psychology, or PsyD required.
At least five years clinical experience required in a related setting.
3 - 5 years of management experience required.
Relevant experience and demonstrated skill in data aggregation and interpretation, analysis and process improvement required.
Experience collecting and interpreting patient information required.
Experience collecting and analyzing performance and incident data at the medical staff and organizational level.
Thorough knowledge of regulatory and accrediting agency standards, rules and regulations (i.e., The Joint Commission, CMMS, DHHS, etc.) required.
Proficient in Microsoft Word, Excel and PowerPoint applications required.
Employees must be in good standing (employment/corrective action history, evaluation, etc.) to be considered for internal transfers.

Keyphrases: psychiatry jobs, psychiatrist jobs, psychologist jobs, psychiatric nurse practitioner jobs

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