• Ensures compliance with state and federal regulations. • Enhances hospital visibility by involvement in community regarding mental health and substance abuse community needs. • May supervise nursing management team where licensed and appropriate. • Functions as a liaison between physicians, patients, referral sources, and employees. • Ensures that the inpatient programs are staffed with the appropriate resources to ensure high quality of care delivery. • Oversees the Infection Control Plan, understand the Infection Control Monitors and the JC Standards associated with Infection Control. • Meets hospitals staffing and budget benchmarks. • Assures adequate supervision and evaluation processes for all staff members and delegate these responsibilities as appropriate. • Assists with orientation for new employees. • Routinely reviews job assignments and utilization of staff. • Monitors the hospitals quality/risk program as needed. • Demonstrates an extensive knowledge of all regulatory standards including TJC, Medicaid, state, and federal laws. • Works with hospital employees to identify risk/safety concerns and leads the team to take correction action as needed. • Collects and analyzes data on hospital performance. • Collects incident reports; records, analyzes, investigates data and reports to Quality Council and CEO. • Utilizes the PDCA method to develop improvement plans for the hospital. • Acts as a role model for excellent customer service and holds all staff to this standard.