ESSENTIAL FUNCTIONS:

Monitors and analyze QM data for review by facility management. Submit data to external agencies as required. Conducts annual preparation and evaluation of the facility Quality plan. Completes QM projects and incorporates the results into patient care improvements. Ensures facility compliance with policies and applicable standards as required by regulatory/accrediting bodies. Submits monthly scorecard data to Acadia corporate office. Completes monthly safety rounds and submit results/corrective actions to Acadia corporate office Reviews incident/safety concerns with the leadership team to identify systemic issues and facilitate the development of       corrective actions. Facilitates/oversees investigation and Root Cause Analyses into all serious and/or sentinel events. Provides staff management to including hiring, development, training, performance management and communication to     ensure effective and efficient department operation. Coordinates the abstraction of clinical data according to Joint Commission specifications and data entry via vendor database for Inpatient Psychiatric Core Measures (HBIPS).

OTHER FUNCTIONS:

Performs other functions and tasks as assigned.