Director of Quality and Accreditation

Overview

Join our team at Bronson Behavioral Health Hospital as our Director of Quality and Accreditation. Bronson Behavioral Health Hospital is a licensed, 96-bed psychiatric treatment facility located in Battle Creek, Michigan. We provide inpatient psychiatric programs for adults experiencing a crisis related to mental health, substance use, or both. The hospital emphasizes evidence-based practices in a safe and therapeutic environment and is committed to accessible, high-quality care that promotes recovery and well-being.

We are seeking a dynamic and experienced Director of Quality and Accreditation to lead the facility’s efforts in ensuring the highest standards of patient care and safety. This leadership role oversees regulatory compliance, quality assurance programs, and continuous improvement initiatives across 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 excellence in care delivery and regulatory readiness.

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, regulations, and accreditation standards. The Director leads and oversees policy development, implementation of clinical protocols and standards, incident reporting, regulatory engagement (including plans of correction), certification achievement and maintenance, oversight of the QAPI program, and ongoing regulatory readiness strategies.

Through routine presence in patient care areas, data analysis and documentation monitoring, the Director fosters a proactive, multidisciplinary focus on quality and excellence.

• Lead and monitor day-to-day regulatory readiness, patient safety, and service excellence across the facility.
• QAPI program oversight and management, including identification, collection, and analysis of quality performance data; use data to drive continuous improvement.
• Coordinate data collection and analysis from all departments; 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.
• Coordinate abstraction of clinical data according to Joint Commission specifications and data entry for Inpatient Psychiatric Core Measures (e.g., HBIPS).
• Lead root cause analyses and evaluation of serious incidents, complaints, and related investigations; develop corrective action plans with facility leadership.
• Ensure regulatory preparedness with sustainable survey preparation and ongoing monitoring, including auditing and early issue identification.
• Collaborate with other departments to implement best practices in regulatory and accreditation compliance and maintain proficiency in regulatory strategies for local, state, and federal bodies.
• Maintain proficiency in electronic platforms used for observations and the electronic medical record, as applicable.
• Serve as a technical advisor and internal consultant on performance improvement tools, analytical methods, and statistical applications; promote a culture of high reliability and zero harm.
• Foster multidisciplinary ownership of self-monitoring, auditing, and process improvement; escalate opportunities as appropriate.
• Develop and implement clinical program excellence, assess fidelity to Acadia standards, and support remediation plans to achieve fidelity to standards.
• Lead the Quality Council, participate in leadership rounds, and communicate findings and corrective actions to the facility CEO and corporate office.

• Perform other functions and tasks as assigned.

• Bachelor’s Degree in Human Services or nursing required. Master’s degree in behavioral health or 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.

While this job description is intended to be an accurate reflection of the requirements of the job, management reserves the right to add or remove duties based on circumstances. We are committed to providing equal employment opportunities to all applicants for employment regardless of characteristics protected by applicable laws.

AHCORP