Director of Regulatory & Quality Improvement - Auburn Hills, MI
Company: Hire Velocity
Location: Auburn Hills
Posted on: August 7, 2022
Psychiatric-Mental Health opening in Auburn Hills, Michigan.
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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.
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
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
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
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
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
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
Assures that hiring, disciplinary actions and termination
procedures are conducted in accordance with hospital policies.
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
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
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,
Proficient in Microsoft Word, Excel and PowerPoint applications
Employees must be in good standing (employment/corrective action
history, evaluation, etc.) to be considered for internal
Keyphrases: psychiatry jobs, psychiatrist jobs, psychologist jobs,
psychiatric nurse practitioner jobs
Keywords: Hire Velocity, Southfield , Director of Regulatory & Quality Improvement - Auburn Hills, MI, Healthcare , Auburn Hills, Michigan
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