Director of Quality and Accreditation

Overview

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.

• 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 (e.g., HBIPS).
• Identify key aspects of care relevant indicators and evaluation of data using formal and informal feedback from consumers of services and other sources 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 sustainable survey preparation and ongoing monitoring processes, including facility-wide auditing and early-issue identification, to maximize achievement of zero- or standard-level survey outcomes.

• Facility-wide support – collaborate with other departments to sustainably implement best-practices in regulatory/accreditation compliance as evidenced by measurable results with regard to survey outcomes, patient safety metrics, patient experience results, HBIPS, etc.
• Develop and maintain proficiency in regulatory planning strategy for all standards for all relevant regulatory and accrediting bodies at the local, state, and federal level.
• Develop and maintain proficiency in the functionality and auditing within electronic platforms such as electronic patient observations and the electronic medical record, as applicable.
• Lead Root-Cause Analyses and conduct timely and regular evaluation of serious incidents, complaints, grievances and related investigations to:
  • Identification of events, trends and patterns that may affect client health, safety and/or treatment efficacy
  • Committee evaluation findings and recommendations submitted to agency management for corrective action
  • Implemented actions, outcomes, trends analyzed over time
• 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.
• Ensure proper reporting of incidents and adverse clinical outcomes to duly authorized enforcement agencies or regulatory agencies as appropriate and/or required.
• In conjunction with assigned corporate Division Quality Director, initiate and lead communications with regulatory agencies as appropriate.
• 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.
• Ensure multidisciplinary ownership of best-practices in self-monitoring, auditing, and process improvement, escalating opportunities…