Director of Quality and Accreditation

About the Role

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. This leadership role oversees 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.

Responsibilities

• Lead and monitor day-to-day regulatory readiness, patient safety, and service excellence across the facility.
• Oversee and manage the QAPI program, including development of processes for identification, collection, and analysis of quality performance data.
• Utilize collected data to drive continuous improvement in service delivery.
• Conduct annual preparation and evaluation of the facility 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 data entry for Inpatient Psychiatric Core Measures (e.g., HBIPS).
• Identify key aspects of care relevant indicators and evaluate data using feedback from consumers and collateral sources to improve service delivery.
• Lead and coordinate data collection and analysis from all facility departments.
• Prepare and present program data trends and action plans to the monthly Quality Council, Medical Executive Committee, and Governing Board.
• Implement sustainable survey preparation and ongoing monitoring processes, including facility-wide auditing and early-issue identification.
• Collaborate with other departments to implement best practices in regulatory and accreditation compliance.
• Develop and maintain proficiency in regulatory planning strategy for all relevant regulatory and accrediting bodies at local, state, and federal levels.
• Develop and maintain proficiency in auditing electronic platforms such as electronic patient observations and the electronic medical record.
• Lead Root-Cause Analyses and evaluate serious incidents, complaints, grievances, and related investigations to identify trends and patterns affecting client health and safety.
• Develop corrective action plans for regulatory vulnerabilities or patient safety risks in collaboration with facility leaders.
• Ensure proper reporting of violations, incidents, and adverse clinical outcomes to authorized enforcement and regulatory agencies.
• Initiate and lead communications with regulatory agencies in conjunction with the corporate Division Quality Director.
• Develop sustainable performance improvement practices through data analysis and prioritization of efforts to improve survey readiness and care delivery.
• Ensure multidisciplinary ownership of best practices in self-monitoring, auditing, and process improvement.
• Ensure strategic and operational implementation of regulatory requirements, guidelines, and standards from federal, state, and local agencies, as well as accrediting organizations.
• Collaborate with Division and Corporate entities to execute strategic quality and patient safety initiatives at the facility level.
• Serve as a technical advisor, educator, and internal consultant on performance improvement tools, analytical techniques, and statistical applications.
• Ensure facility compliance with policies and applicable standards required by regulatory and accrediting bodies.
• Serve as the facility leader and subject matter expert on high reliability principles and strategies to achieve zero harm.
• Assess fidelity to Acadia standards and identify root causes for gaps or lapses, supporting departments in developing remediation and improvement plans.
• Develop, review, and educate on internal clinical procedures and outcome evaluation tools to ensure continuous quality improvement and compliance.
• Translate standards, requirements, and policies into meaningful processes for the facility.
• Serve as a visible, engaged, and dynamic member of the facility leadership team.
• Chair the monthly Quality Council and participate in leadership rounding.
• Review incident and safety concerns with the leadership team to identify systemic issues and facilitate corrective actions.
• Lead and facilitate Root Cause Analyses into serious and/or sentinel events.
• Invest in facility staff through hiring, development, training, performance management, and communication.
• Oversee the Culture of Safety Survey and follow-up action planning and sustainment processes.
• Identify problems or potential risks to patients and staff and propose corrective steps, including policy changes, staffing adjustments, additional training, or service modifications.

Requirements

• Bachelor’s Degree in Human Services or nursing required; Master’s degree in behavioral health/risk discipline or Registered Nurse preferred.
• Two or more years of experience in a Quality, Clinical, or Process Improvement role required.
• One or more years of management experience preferred.
• Experience with CARF, DEA, Joint Commission, or CMS surveys, as required by service line(s) supported.
• Current licensure appropriate for the degree held required.
• CPR and de-escalation/restraint certification required (training available upon hire and offered by facility).
• First aid certification may be required based on state or facility.