Director of Quality and Accreditation

Overview

West Pines Behavioral Health is 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.

West Pines Behavioral Hospital is a leading provider of mental health and substance use treatment for Westminster, Colorado, and surrounding communities. With more than three decades of experience and a full continuum of care, we can effectively address a wide range of symptoms and concerns. Through evidence-based treatments and personalized support, we strive to promote wellness, foster healing, and improve the lives of our patients and their families.

Learn more here:

West Pines Behavioral Health

• Competitive compensation with industry leading annual performance-based bonus opportunity
• Comprehensive benefits including medical, dental, and vision insurance
• 401(k) with company match to support your financial future
• Stock-based awards
  , giving you a stake in Acadia’s success
• Generous paid time off for vacation, sick days, and holidays
• Professional development & leadership training to sharpen your skills
• Career mobility within Acadia’s nationwide network of 250+ facilities

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. As such, the Director is responsible for leading and overseeing 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 on‑going 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.

• Lead and monitor day‑to‑day regulatory readiness, patient safety, and service excellence across the facility.
• QAPI program oversight and management – follow and develop processes for identification, collection, and analysis of quality performance data.
  • Utilize collected data regarding the outcome of activities for delivering continuously improving services.
  • Conduct annual preparation and evaluation of the facility QAPI Program.
  • Complete process improvement projects and incorporate the results into patient care improvements.
  • Submit quality scorecard data to Acadia corporate office as requested.
  • Coordinate the abstraction of clinical data according to Joint Commission specifications and data entry via vendor database for Inpatient Psychiatric Core Measures (ex. national quality measures such as HBIPS).
  • Identify key aspects of care relevant indicators and evaluation of data using formal and informal feedback from consumers of services and other collateral sources is aggregated and used to improve management strategies and service delivery practices.
  • Lead/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 the Governing Board.

• Regulatory preparedness – implement…