Perimeter Behavioral Hospital of Jackson is a residential and acute treatment facility providing care to adolescents. Located in Jackson, TN. Perimeter Behavioral of Jackson's goal is to provide a responsive healing environment for patients and to inspire hope and contribute to health and well-being by providing the best care to every patient through integrated clinical practice, education, and compassion. Join our professional team today.

POSITION TITLE: Director of Quality and Risk Management

DEPARTMENT: Administrative

REPORTS TO: Chief Executive Officer, dotted reporting to Home Office VP of Quality and Risk Management

POSITIONS SUPERVISED: None

FLSA STATUS: Exempt

DATE DEVELOPED/REVISED: April 25, 2019

WORKDAYS, /HOURS: Fulltime status. Schedule arranged in consultation with the CEO. Rotating AOC expected
REQUIRED KNOWLEDGE, SKILLS AND EDUCATION
Minimum of two to five years clinical experience in treatment services to children, adolescents, geriatric, and families in acute, residential, and outpatient settings
A degree e.g. nursing or social work; licensure is expected in the area of expertise
Considerable knowledge of Inpatient Acute Care Hospitalization, Residential Treatment Centers, Intensive Outpatient Programs, and Partial Hospitalization Programs
Knowledge of state, federal, governmental and regulatory agency regulations pertaining to inpatient/residential treatment
Experience and skill in communicating with impact to effectively engage others and achieve desired results
Experience and skill in handling multiple conflicting assignments, demands, and priorities with attention to details. Additionally, experience and skill in developing ideas and solutions in response to clinical issues and barriers
Willingness to focus on employee development through exposure, experiences, and feedback
Strong organizational, analytical, writing and verbal communication skills, and

the ability to use qualitative and quantitative outcomes and analysis data to

identify performance gaps, initiate training and mentoring to assist clinicians,

clinical teams and direct care staff to deliver quality behavioral healthcare.

Ability to communicate and promote cooperation within facilities with the management team, staff, patients and their families to include the ability to project a favorable, professional image in the public. Additionally, ability to withstand diverse, voluminous work responsibilities and the corresponding pressures and to display sound physical and mental health
OTHER REQUIRED KNOWLEDGE AND SKILLS
LANGUAGE SKILLS: Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and policy/procedure manuals. Ability to write routine reports. Ability to speak effectively before groups of residents or employees of an organization
REASONING ABILITY: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form
PHYSICAL DEMANDS: While performing the duties of this job, the employee is regularly required to stand; walk; sit; use hands and arms; climb or balance; stoop, kneel, crouch, or crawl; and talk or hear. The employee must occasionally lift and/or move a minimum of 50 pounds. Specific vision abilities required by this job include close, distant, and peripheral vision, color and depth perception, and ability to adjust focus
MENTAL REQUIREMENT: Ability to exercise self-control in potentially volatile situations. Must be able to work and concentrate amidst distractions such as noise, conversation and foot traffic. Must be flexible and able to complete multi-tasks without overwhelming frustration
WORK ENVIRONMENT: The work environment for this position is a basic office environment in a facility setting. However, while performing the duties of this job, the employee may be exposed to clients who may ask inappropriate personal questions, display socially unacceptable personal behaviors, use profanity and sexually explicit phrases, make insulting remarks or threats regarding appearance, age, sex, or race, exhibit defiance, dishonesty, and assaultive or self-destructive behaviors. The employee is occasionally exposed to outside weather conditions. The employee is occasionally exposed to fumes or airborne particles. The noise level in the work environment is usually moderate

Essential Job Function And Responsibilities

Works collaboratively with senior leadership, hospital leaders, physicians and staff to reduce risk and promote quality patient care and safety. This is accomplished through various assessment activities and corrective actions through the monthly Quality/Patient Safety Committee/Committee of the Whole or ad hoc meetings. Manages and coordinates efforts to ensure that quality management programs are developed and managed using a data driven focus and sets priorities for improvements aligned to ongoing strategic imperatives.

Assures hospital-wide quality management, performance improvement initiatives and patient safety program are focused and aligned on improving care, operational and program efficiencies and effectiveness; provides ongoing leadership for performance improvement and patient safety development with hospital leaders.

Assess and improve the quality of patient care services provided by developing an integrated system of quality management, resource utilization, patient safety and risk management.

PERFORMANCE JOB EXPECTATIONS

Compliance/Legal

Ensure patient services are provided without discrimination and receptive consideration for diversity, cultural/religious sensitivity and respect for presenting disability
Familiar with and promotes compliance with federal/state acts and regulations through policy development, guidance and educational programs. Including not limit to orientation of: Patient Privacy, OSHA, Americans with Disability Act-ADA, CMS-CoPs, Emergency Medical Treatment and Active Labor Act-EMTALA, Health Care Quality Improvement Act-HCQI, Health Insurance Portability and Accountability Act-HIPAA, National Practitioner Data Bank, Occupational Safety and Health Administration-OSHA, Safe Medical Device Act-SMDA and Stark Law
Provides ongoing communication with the Corporate Compliance Officer at the Home Office
Ensure the Code of Conduct educated to new employees and documented in the employee file
Ensures a solid patient rights and advocacy/complaint/grievance program is maintained and managed with strong processes
Assist Corporate Compliance Officer and/or legal counsel in investigative efforts, risk assessments and procedural activities
Assist with business associate agreements with those required to access protected health information and coordinates contract review with the Corporate Compliance Officer at home office
Demonstrates the ability to adhere to the professional code of ethics and the organization’s policies/procedures, to include confidentiality, patient rights, and continuing education
Demonstrates the ability to maintain a professional and productive work atmosphere by professional behavior, communicating in a manner that promotes cooperation and teamwork with home Office members, facility staff, supervisors, patients and visitors
Ensure HIPAA Education
Ensure going compliance by communication with Corporate Compliance Officer at the home office for any compliance issues presented at the facility

Licensing and Accreditation

Ensures policies and procedures conform to Joint Commission (with Deemed Status as applicable), state specific licensing and specific payer requirements. Implements systems to ensure continue readiness including planning for evolving/new standards updates annually
Self-monitoring activities-assessments are regularly scheduled using the tracer methodology, tabletop exercises, chart reviews, surveillance rounds
Facilitates preparation, implementation and on-going monitoring follow-up of regulatory/accreditation site visits

Quality Management-Performance Improvement

Chairs and monitors, tracks, trends, analyze all Key Performance Indicators-KPIs monthly Quality/Patient Safety Committee or Committee of the Whole
Facilitates and collaborates with facility leaders, derived from facility KPIs and industry, to evolve a quality improvement program in support of positive patient outcomes and safety

Patient Safety/Risk Management

Designs, implements, and follows the Quality/Patient Safety Plan and annually update the plan assessing if goals are met, need continuation or revision
Implements and monitors incident reporting / evaluation. Initiates corrective actions when indicated
Ensure an annual improvement project related to patient safety initiative identified through risk prioritization. Document accordingly to reflect the project work utilizing the Quality/Patient Safety Plans’ framework of DMAIC
Provides a continuous learning and just culture approach to all investigations of safety events and liability cases
Provides annual and new hire quality and risk management/performance improvement training as well as individualized and small group training as needed
Facilitate and promote the organization risk management program to ensure safety

Patient Outcomes

Facilitates and collaborates with facility leaders to evolve a quality improvement program in support of positive patient outcomes and safety
Support the efforts of the Patient Outcomes inclusive of Patient Satisfaction and Therapeutic Outcomes and aligning of KPIs

Leadership

Morning meeting attendance may be necessary as determined by the CEO
Administrator on Call Assignment-AOC may be necessary as determined by the CEO
All other duties as assigned

If you would like to learn more about joining our team, please visit our website at https://www.perimeterhealthcare.com

Perimeter Healthcare is one of the leading mental and behavioral health care providers in the country. We deliver hope to our patients through the delivery of comprehensive and dedicated treatment programs. Our focus and commitment on service excellence is available across several states and different care settings. Our team ensures you receive the required care that you or your loved one needs. We offer several settings for our patients including inpatient psychiatric hospitals, residential treatment centers as well as outpatient counseling and therapies.

EEO

We are committed to providing an environment of diversity and inclusion where equal opportunities are available to all applicants and fellow employees. Perimeter Behavioral Health is an equal opportunity employer regarding all recruitment, training, and selection process within the company in regard to race, color, religion, age, sex, sexual orientation, pregnancy, and gender identity, genetic information, national origin, disability status, protected veteran status, or any other characteristic protected by federal, state, or local laws.

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