Director of Quality and Accreditation

About the Role

We are seeking a dynamic and experienced Director of Quality and Accreditation to lead our facility’s efforts in ensuring the highest standards of patient care and safety. This leadership role is responsible for overseeing regulatory compliance, quality assurance programs, and continuous improvement initiatives across all clinical and operational areas. The Director will guide the development and implementation of quality protocols, manage accreditation processes, and lead the Quality Assurance and Process Improvement (QAPI) program.

Purpose Statement

The Director of Quality and Accreditation is responsible for ensuring patient safety and superior quality of care as measured by survey readiness, treatment program fidelity, and compliance with state and federal laws and regulations and accreditation standards. The Director leads and oversees all aspects of policy development; comprehensive implementation of Acadia’s prescribed clinical protocols, operational quality oversight standards, and programmatic expectations; critical incident reporting; regulatory engagement, including development and submission of plans of correction; certification achievement and maintenance; oversight of the quality assurance and process improvement (QAPI) program; and ongoing regulatory readiness strategies at the facility.

Through routine physical presence in patient care areas, data analysis and documentation monitoring, and intentional sharing of deep subject‑matter expertise, the Director will ensure a proactive, multidisciplinary focus on quality and excellence within the facility.

Essential Functions

• Lead and monitor day‑to‑day regulatory readiness, patient safety, and service excellence across the facility.
• Oversee the QAPI program: develop processes for identification, collection, and analysis of quality performance data; utilize data to continuously improve services; conduct annual preparation and evaluation of the QAPI program; complete process improvement projects and incorporate results into patient care improvements; submit quality scorecard data to Acadia corporate office as requested.
• Coordinate abstraction of clinical data according to Joint Commission specifications and enter data via vendor database for Inpatient Psychiatric Core Measures (e.g., HBIPS); identify key care indicators and evaluate data using feedback from service consumers and other sources to improve management strategies and service delivery.
• Lead/coordinate data collection and analysis from all departments; prepare and present program data trends and action plans to the monthly Quality Council, quarterly to the Medical Executive Committee, and to the Governing Board.
• Implement sustainable survey preparation and ongoing monitoring processes, including facility‑wide auditing and early‑issue identification, to achieve zero‑ or standard‑level survey outcomes.
• Collaborate with other departments to implement best practices in regulatory/accreditation compliance, demonstrated by measurable results in survey outcomes, patient safety metrics, patient experience, HBIPS, etc.
• Develop and maintain proficiency in regulatory planning strategies for all relevant standards at local, state, and federal levels.
• Develop and maintain proficiency in electronic platforms such as electronic patient observations and the electronic medical record, including auditing functionality.
• Lead Root‑Cause Analyses and conduct timely evaluation of serious incidents, complaints, grievances, and related investigations; identify trends affecting client health, safety, or treatment efficacy; submit findings and recommendations for corrective action; develop corrective action plans in collaboration with facility leaders.
• Ensure proper reporting of violations, incidents, and adverse clinical outcomes to authorized enforcement or regulatory agencies as required.
• In conjunction with the corporate Division Quality Director, initiate and lead communications with regulatory agencies as appropriate.
• Develop sustainable performance improvement practices through data analysis and prioritization to improve survey readiness and consistency of care delivery using best practices.
• Ensure multidisciplinary ownership of best practices in self‑monitoring, auditing, and process improvement; escalate opportunities for improved engagement to the facility CEO as appropriate.
• Implement strategic and operational regulatory requirements, guidelines, and standards of federal, state, and local licensing agencies, accrediting and certifying organizations.
• Collaborate with division, corporate, and external parties to fully execute strategic quality and patient safety initiatives at the facility level.
• Facilitate effective communication with facility and division leadership regarding key clinical performance improvement activities and initiatives.
• Serve as a technical advisor, educator, and internal consultant to hospital management, staff, and physicians on performance improvement tools, analytical techniques, and statistical applications.
• Ensure facility compliance with policies and applicable standards required by regulatory/accrediting bodies.