Director of Quality and Accreditation

Rio Vista Behavioral Health Hospital • El Paso, TX

282d

About The Position

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. 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.

Requirements

• Bachelor's Degree in Human Services or nursing required.
• Master's degree in behavioral health/risk discipline preferred.
• 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 required.

Nice To Haves

• Current licensure appropriate for the degree held required.
• CPR and de-escalation/restraint certification required.
• First aid may be required based on state or facility.

Responsibilities

• Lead and monitor day-to-day regulatory readiness, patient safety, and service excellence across the facility.
• Oversee and manage the QAPI program, developing processes for identification, collection, and analysis of quality performance data.
• 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.
• Identify key aspects of care relevant indicators and evaluate data using feedback from consumers and other sources.
• Lead/coordinate data collection and analysis from all departments within the facility.
• Prepare and present program data trends and action plans to the Quality Council and Medical Executive Committee.
• Implement sustainable survey preparation and ongoing monitoring processes.
• Collaborate with other departments to implement best practices in regulatory/accreditation compliance.
• Develop and maintain proficiency in regulatory planning strategy for all standards.
• Lead Root-Cause Analyses and evaluate serious incidents and complaints.
• Develop corrective action plans for areas of regulatory vulnerability.
• Ensure proper reporting of violations or potential violations to enforcement agencies.
• Initiate and lead communications with regulatory agencies.
• Develop sustainable performance improvement practices through data analysis.
• Ensure multidisciplinary ownership of best practices in self-monitoring and auditing.
• Facilitate effective communication with facility and division leadership.
• Serve as a technical advisor and educator on performance improvement tools.
• Ensure facility compliance with policies and applicable standards.
• Assess fidelity and identify root-causes for gaps in fidelity to standards.
• Develop, review, and educate on internal clinical procedures and outcome evaluation tools.
• Translate standards, requirements, and policies into meaningful processes.
• Serve as a visible, engaged member of the facility leadership team.
• Chair the monthly Quality Council.
• Complete safety rounds and participate in leadership rounding.
• Review incident/safety concerns with the leadership team.
• Lead and facilitate Root Cause Analyses into serious events.
• Invest in facility staff through engagement in hiring and training.
• Oversee the Culture of Safety Survey and follow-up action planning.
• Identify problems to prevent risks to patients and staff.

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Industry: Hospitals
• Education Level: Bachelor's degree