Director of Quality and Risk

About Us NeuroPsychiatric Hospitals is a national leader in behavioral healthcare, specializing in patients with acute psychiatric and complex medical needs. Our hospitals use an interdisciplinary, multi-specialty approach that delivers high-quality, patient-centered care when it's needed most. With locations in I ndiana, Michigan, Texas, and Arizona, we're expanding access to our unique model of care across the United States. Join us and be part of a team dedicated to making a lasting difference in the lives of patients and families every day Overview NeuroPsychiatric Hospitals is looking for a Director of Quality and Risk at our Houston, Texas location. NPH is the national leader in providing medical and neurobehavioral care to patients in acute psychiatric distress. You will be joining a team of rock star staff who provide exceptional, patient-centered care and understand our patients are always our number one priority! The Director of Quality supports the implementation and monitoring of the quality assurance measurements and audits, and assists in improving patient safety processes throughout the hospital through coordinating and engaging in activities to proactively promote implementation of evidence based best practices and resolve deficiencies; plans, develops, and directs system activities and protocols across NeuroPsychiatric Hospitals; helps to prepare NPH facilities for surveys by accrediting and licensing agencies; serves as a resource to all departments and personnel. Benefits of joining NPH as a Director of Quality and Risk Competitive compensation Industry recognized benefits, including Medical, Dental, and Vision Insurance NPH 401(k) plan with up to 4% Company match Employee Assistance Program (EAP) Programs Generous PTO and Time Off Policy Special tuition offers through Capella University Work/life balance with great professional growth opportunities Employee Discounts through LifeMart Responsibilities Implements and monitors quality goals and objectives to measure the organization's processes and outcomes while administering programs that focus on improved outcomes of patient care or patient safety. Interacts with physicians, nurses, department managers, supervisors, and any/all other staff members to provide resource information and identify new opportunities to improve service and reduce costs. Generates effectual quality related policies and procedures for the department and hospital that ensures compliance with JC, OSHA, CDC, CMS and other county, state, and federal regulatory agencies. Prepares reports, presentations and statistical data that go to the Quality Assurance and Performance Improvement Committee Meetings, facility's administration and other committees as needed. Analyzes data to identify trends and resource utilization for use in optimizing compliance. Assists with the annual assessment of the quality control programs from the prior year activities. Investigates incidents within the facility and coordinates with the Corporate Quality team to complete the root cause analysis and develop action plans to prevent incidents in the future. Establish a structure to ensure that patient care activities are addressed in a coordinated manner involving quality improvement. Prepares the agenda for the Quality Council Committee meetings and holds regularly scheduled meetings. Provides educational offerings for orientation and on-going in-services. Performs mortality reviews in conjunction with the mortality committee and holds regularly scheduled mortality committee meetings. Ensures all staff receive proper education on new or revised state and/ or federal regulations or Joint Commission standards. Participates in Multi-disciplinary patient centered case conferences, as appropriate. Assess and evaluate patients with infections and monitor patient outcomes on an ongoing basis. Initiates follow-up on employee/patient exposures to communicable diseases. Participates in root-cause analysis, sentinel events, adverse events and identifies trends as directed by regulation. Recommends ways to redesign systems for improvements if needed. Oversee Patient Advocacy program. Establishes/maintains good relationships with COO, CEO and DON's and department leaders to promote a cooperative and constructive environment for improvement. Promote "Quality is everyone's business" to gain support, understanding and ownership among staff. Other duties as may be assigned. Complies with hospital expectations regarding ethical behavior and standards of conduct. Complies with federal and hospital requirements in the areas of protected health information & patient privacy. Understands and adheres to NPH's compliance standards as they appear in NPH's Corporate Compliance Policy, Code of Conduct and Conflict of Interest Policy. Keeps abreast of all pertinent federal, state and hospital regulations, laws and policies as they presently exist and as they change or are modified. Per #J-18808-Ljbffr Neuropsychiatric Hospitals