Director of Quality and Accreditation

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 policy development, implementation of clinical protocols, operational quality oversight, critical incident reporting, regulatory engagement, certification achievement and maintenance, oversight of the QAPI program, and ongoing regulatory readiness strategies.

Essential Functions

• Lead and monitor day-to-day regulatory readiness, patient safety, and service excellence across the facility.
• Oversee and manage the QAPI program, including identification, collection, and analysis of quality performance data.
• 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 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).
• Lead and coordinate data collection and analysis from all departments within the facility.
• Prepare and present program data trends and action plans to the monthly Quality Council and quarterly to the 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/accreditation compliance.
• Develop and maintain proficiency in regulatory planning strategy for all relevant regulatory and accrediting bodies.
• Develop and maintain proficiency in 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.
• Develop corrective action plans for areas of regulatory vulnerability or patient safety risks.
• Ensure proper reporting of violations or potential violations to enforcement agencies as required.
• Ensure proper reporting of incidents and adverse clinical outcomes to regulatory agencies as required.
• Initiate and lead communications with regulatory agencies in conjunction with corporate Division Quality Director.
• Develop sustainable performance improvement practices through data analysis and prioritization of efforts.
• Ensure multidisciplinary ownership of best-practices in self-monitoring, auditing, and process improvement.
• Ensure strategic and operational implementation of regulatory requirements, guidelines, and standards.
• Collaborate with Division and Corporate entities and external parties to execute quality and patient safety initiatives.
• Facilitate effective communication with facility and division leadership regarding clinical performance improvement activities.
• Serve as a technical advisor, educator, and internal consultant on performance improvement tools and techniques.
• Ensure facility compliance with policies and applicable standards.
• Serve as facility leader and subject matter expert on high reliability principles and strategies to achieve zero harm.
• Assess fidelity and identify root-causes for gaps in fidelity to standards.
• Support other departments in developing and implementing remediation and improvement plans.
• Develop, review, and educate on internal clinical procedures and appropriate use of outcome evaluation tools.
• Translate standards, requirements, and policies into terms or processes meaningful to the facility.
• Serve as a visible, engaged, and dynamic member of the facility leadership team.
• Chair the monthly Quality Council.
• Complete safety rounds, participate in leadership rounding, and submit results/corrective actions.
• Review incident/safety concerns with the leadership team to identify systemic issues.
• Lead and facilitate Root Cause Analyses into all serious and/or sentinel events.
• Invest in facility staff through engagement in 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 problems to prevent risks to patients and staff.
• Propose corrective steps such as changes in policies/procedures, staffing changes, additional education or training, and addition or deletion of services.

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.