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E00357 – Regional Quality Assurance Strategist




Position Overview: Under the supervision of the Corporate Director of Clinical Quality Assurance and in collaboration with the facility CEO’s, the Quality Assurance Strategist is responsible for the regional implementation, management, coordination and oversight of RCA’s Quality Assurance (QA) Performance Improvement (PI), and Compliance activities occurring within the Maryland Inpatient Treatment Facilities; encompassing both detoxification and residential levels of care. The Regional Quality Assurance Strategist will provide direct supervision to site Quality Assurance Assistants to ensure daily responsibilities are successfully completed and proactive mitigation of risk occurs daily. The Regional Quality Assurance Strategist is responsible to ensure data reporting and trending is utilized to implement continuous quality monitoring and targeted performance improvement initiatives to ensure standardization, consistency, and high-quality care is provided within the regional boundaries. Daily Oversight and Responsibilities Include: * Chart Audits o Monthly Qualitative Chart Audits (10% of prior months discharges) o Daily chart audits based on priority issues and/or PIP/CAPs/DCOs o Ensure PIP follow up and correction for areas of concern  Follow up with all staff regarding results of all audits, compile summary * QA Reports o Morning FLASH Briefing o Morning leading dissemination of deficiency reports/docs due o Working with leadership to ensure documentation timeliness and completion o End of day dissemination of continued areas of deficiency reports/docs due o Monthly Compliance Summary Response (sent by compliance dept) o QA report education (how to read, how to verify) * Incident Reports o FLASH briefing o Disseminate IR (i.e. high to low; if it needs to be sent to DMHAS, etc.) o Manage IR  Prepare to discuss/identify trends in daily meeting  Ensuring all are investigated with interviews and collecting data  Ensure all are closed  Follow up with team to make sure incident follow up is completed  Follow up with KOP team for any state reporting requirements o IR re-training/re-education is done o Send weekly IR reports to KOP o Conduct investigation (interviews, review of footage, root cause as needed) * Grievances o Follow up and respond to all patient grievances daily o Send weekly Grievance reports to KOP o Utilize ACTS for grievances * Patient Satisfaction Surveys o FLASH briefing o Patient Sat daily tracking and weekly aggregation o Distribute, collect, and prepare data for leadership to present at QAPI o Follow up with patients refusing to complete o Follow up on weekly comments to ensure response to comments * Co-Chair the following Committee Meetings with Site Leadership: o QAPI Committee Meeting- Monthly  Serves as the QAPI Co-Chair/site Leadership as Chair (as appointed by CEO)  Complete QAPI Presentation/Summary Sheet  Ensures follow through on Senior Leadership PIPs o Medical Records Committee Meeting -Monthly  Medical Records Co-Chair/site Leadership as Chair (as appointed by CEO)  Aggregate data and prepare reports/identify trends  Complete Medical Records Presentation/Summary Sheet  Ensures follow through on Senior Leadership PIPs o Safety Committee Meeting -Monthly  Safety Co-Chair/site Leadership as Chair (as appointed by CEO)  Prepare data and summary sheet  EOC checks/safety checks o Infection Control Committee-Quarterly  Co-Chair/Medical Director and/or DON Chair  Monitoring of Risk Assessment and Plan o Pharmacy and Therapeutics Meeting  Co-Chair/ Medical Director and/or DON Chair  Review of standing agenda o Weekly Leadership Meetings  Provide leadership with weekly data/information as requested  Assist in development of performance improvement plans as needed * Monthly Environment of Care Walkthroughs o Participate in ECO walkthroughs and document areas for improvement. o Assist in development and monitoring of PIPs as needed * Policy & Procedure and Protocol Governance o Ensures dissemination and understanding of approved P&Ps  Update P&P manual on site o Ensure protocol development has been reviewed/approved by governing committee o Ensure facility feedback prior to P&P meeting on upcoming P&P * Plan of Corrections (DCOs, CAPS, PIPS) o Assist in development o Monitor completion o Ensure appropriate follow up * Regulatory and Accreditation Awareness/readiness o Training on regulatory and accrediting requirements o TJC intracycle monitoring * Survey and Survey Prep o Assist in state, local, accrediting body preparation o Serve as site liaison during on site survey Overall Strategic Responsibilities: * Strategic oversight encompasses all organizational and regional areas to include but not limited to: risk management, patient satisfaction surveys, regulatory/payor/accreditation compliance, clinical outcomes management, clinical programming, quality management committees, coordination of care, models of supervision, system validity/reliability, and operational efficiency. Strategic oversight includes: o Implementation and monitoring of performance improvement plans and strategies o Proactive analysis of systems and processes that underscore adverse/high-risk events and/or decline in measurement scores and implement action steps to address o Proactive project management for implementation of quality initiatives o Ongoing survey readiness and education of all levels of staff in regulatory, accreditation, and organizational expectations Education and Experience: * Bachelor’s degree in a related field (healthcare management, psychology, social services, nursing); master’s preferred * Five years of administrative and/or clinical experience and five years quality management experience with a focus on behavioral healthcare * Understanding of systems of quality measurement/management and evidence based practices (American Society of Addiction Medicine, Substance Abuse and Mental Health Services Administration, Healthcare Effectiveness Data Information Set, National Committee for Quality Assurance, National Institute on Drug Abuse, National Alliance on Mental Illness) * Understanding of Risk Management best practices as governed by the American Hospital Association, American Society for healthcare risk management * Previous experience implementing systems and process to include organizational change management * Understanding of managed care to include commercial insurance and CMS governance (Medicaid/Medicare) * Experience and knowledge of ongoing survey readiness and survey processes to include federal regulations, state regulations, Joint Commission, and Commission on Accreditation of Rehabilitation Facilities (CARF surveys and standards. * Experience working with and developing solutions within electronic health records * Proficiency in Microsoft Office products (Office, Excel, Project) * Excellent organizational skills required Competencies: Customer Service: Demonstrates concern for meeting internal and external customers’ needs in a manger that provides satisfaction for the customer within the resources that can be made available. Impact and Influence: Works effectively with and through others including those whom there is no formal authority over. Project Management: Coordinates the diverse components of the project by balancing scope, time, cost, and quality. Communication: Communicates well both verbally and in writing, creates accurate and punctual reports, delivers presentations, shares information and ideas with others, has good listening skills. Work Environment: This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, and filing cabinets. The noise level in the work environment is usually moderate. Physical Demands: While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands to finger, handle or feel objects, tools or controls. The employee is occasionally required to stand; walk; sit; reach with hands and arms; climb or balance; and stoop or kneel. Specific vision abilities required by this position include close vision, distance vision, color vision, peripheral vision and the ability to adjust focus. Travel: 50% travel is required which includes regional, local, and overnight travel


Job Location: Recovery Centers of America at Bracebridge Hall – 314 Grove Neck Road, Earleville, Maryland 21919