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. The ideal candidate will be a proactive, strategic thinker with a strong commitment to achieving excellence in care delivery and regulatory readiness.

Responsibilities

• Lead and monitor day-to-day regulatory readiness, patient safety, and service excellence across the facility.
• Oversee the QAPI program, including identification, collection, and analysis of quality performance data.
• Utilize collected data to deliver continuously improving services and conduct annual preparation and evaluation of the facility QAPI Program.
• Submit quality scorecard data to Acadia corporate office as requested and coordinate the abstraction of clinical data according to Joint Commission specifications.
• Identify key aspects of care relevant indicators and evaluation of data using formal and informal feedback from consumers of services and other collateral sources.
• Lead/coordinate data collection and analysis from all departments within the facility and prepare and present program data trends and action plans to the monthly Quality Council and quarterly to the Medical Executive Committee and the Governing Board.
• Implement sustainable survey preparation and ongoing monitoring processes to maximize achievement of zero- or standard-level survey outcomes.
• Collaborate with other departments to sustainably implement best-practices in regulatory/accreditation compliance and develop and maintain proficiency in regulatory planning strategy for all standards for all relevant regulatory and accrediting bodies.
• Lead Root-Cause Analyses and conduct timely and regular evaluation of serious incidents, complaints, grievances, and related investigations.
• Develop corrective action plans for the resolution of areas of regulatory vulnerability or those which could compromise patient safety in collaboration with other facility leaders.
• Ensure proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required.
• Develop sustainable performance improvement practices through analysis of data and prioritization of efforts to improve survey readiness and consistency of care delivery using expected best-practices.
• Collaborates with Division and Corporate entities and external parties to ensure strategic quality and patient safety initiatives are fully executed at the facility level.
• Facilitates effective communication with facility and division leadership regarding key clinical performance improvement activities and initiatives.
• Serves as a technical advisor, educator, and internal consultant to all hospital management, staff, and physicians on the use of performance improvement tools and techniques, analytical techniques, and statistical applications.
• Ensure facility compliance with policies and applicable standards as required by regulatory/accrediting bodies.
• Facility leader and subject matter expert on high reliability principles and strategies to achieve zero harm.
• Clinical program excellence – assess fidelity and identify root-causes for gaps/lapses in fidelity to Acadia standards.
• Develop, review, and educate on internal clinical procedures and appropriate use of outcome evaluation tools and the associated results.
• Translate standards, requirements, and policies into terms or processes meaningful to the facility.
• Leadership – serve as a visible, engaged, and dynamic member of the facility leadership team.
• Chairs the monthly Quality Council and completes safety rounds, participates in leadership rounding, and submits results/corrective actions to Acadia corporate office.
• Review incident/safety concerns with the leadership team to identify systemic issues and facilitate the development of corrective actions.
• Lead and facilitate Root Cause Analyses into all serious and/or sentinel events.
• Invest in the facility staff through engagement in hiring, development, training, performance management, and communication to ensure effective and efficient operations.
• Oversees the Culture of Safety Survey and follow-up action planning and sustainment processes.

Qualifications

• Bachelor’s Degree in Human Services or nursing required.
• Master’s degree in behavioral health/risk discipline, Registered Nurse preferred.
• Two or more years of experience in a Quality, Clinical, or PI 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 may be required based on state or facility.