Risk Management Director

The Blackberry Center, a serene and retreat-like psychiatric hospital, is licensed by the Florida Department of Health and holds accreditation from The Joint Commission. With a capacity of 64 beds, the center offers a tranquil environment conducive to patient healing. It provides a comprehensive range of mental health programs, including dual diagnosis treatment and general psychiatric care, which can be personalized to cater to the unique needs of each patient.

The individual assigned to the Director of QAPI/Risk position is responsible for the development and maintenance of the Quality Assurance and Performance Improvement functions of the hospital. Responsible for maintaining facility compliance with Joint Commission/ CMS, State and Federal regulatory agencies. Responsible for the development, implementation and management of the Risk Management and Safety program.

RESPONSIBILITIES

• Responsible for the provision, orientation and training of facility staff members on Performance Improvement initiatives facility wide, including the hospital’s Performance Improvement Plan.

• Coordinates and communicates new directives, policies, and procedures to facility staff.

• Coordinates Quality Improvement activities for all departments to ensure facility compliance with Joint Commission/CMS, State and Federal regulatory agencies.

• Works closely with Patient Advocate on any State non-compliance regarding policies affecting the rights of patients and any investigations that may occur.

• Coordinates and provides support services for all Performance Improvement activities and reviews.

• Provides information and compliance standards to staff in the following areas: Problem assessment techniques, including criteria development, data retrieval and display, data analysis and confidentiality of Performance Improvement data.

• Revision and review of hospital policies and procedures as needed.

• Responsible for the coordination of corrective action plans emanating from Joint Commission, Federal and State licensure bodies.

• Responsible for monitoring facility compliance with corrective action plans to ensure ongoing safe quality of patient care improvements for the facility.

• Responsible for conducting ongoing facility mock surveys to ensure facility compliance with regulations.

• Conducts ongoing audits of all departments to ensure to ensure facility compliance with Joint Commission/CMS, State and Federal regulatory agencies.

• Assist other Department Heads in formalizing work groups to investigate problems, determine corrective actions and prepare required reports as necessary and works with Department Heads with the management of department-specific data.

• Maintains documentation of the integration of the Performance Improvement activities facility wide as outlined in the facility wide Performance Improvement plan.

• Performs Performance Improvement activities, including medical record audits, data collection with analysis to include conclusions and recommendations.  Provides QA/PI Committee with aggregate data on all hospital-wide data, and places the data in refined formats. Leads or manages process improvement activities.

• Coordinates the assemblage of records for review by Federal, State, professional and appropriate facility groups.

  EXPERIENCE/EDUCATION:

• Bachelor’s Degree as a Registered Nurse

• Minimum of 3 years’ experience in Quality - Assurance/Performance Improvement is preferred.

• Knowledge of current Joint Commission, CMS, DCF, AHCA, Federal and State standards.

• Knowledge of QA/PI concepts.

• State licensure as a Registered Nurse and maintains current licensure per State requirements. 

  This position requires a pre-employment drug test as well as a Level 2 Background check: https://info.flclearinghouse.com