Director of Quality and Accreditation

Montrose Behavioral Health Hospital - Adult Campus•Chicago, IL

1d•$95,401 - $110,242•Onsite

About The Position

Montrose Behavioral Health Hospital is seeking a Director of Quality and Accreditation to lead regulatory compliance, quality assurance, patient safety, accreditation, and continuous improvement across the facility’s clinical and operational areas. The Director is responsible for survey readiness, treatment program fidelity, compliance with applicable laws and regulations, policy development, implementation of clinical protocols and operational quality standards, critical incident reporting, regulatory engagement, certification, and oversight of the Quality Assurance and Process Improvement (QAPI) program. The role requires routine presence in patient care areas, data analysis, documentation monitoring, and sharing subject-matter expertise to promote a proactive, multidisciplinary focus on quality and excellence. The Director serves as a visible member of the facility leadership team and works with facility departments, division and corporate entities, external parties, and regulatory agencies. The position also provides technical advice and education to hospital management, staff, and physicians on performance improvement tools, analytical techniques, and statistical applications. The listed salary range is $95,401–$110,242.

Requirements

Bachelor’s degree in Human Services or nursing required.
Two or more years of experience in a Quality, Clinical, or PI role required.
Experience with CARF, DEA, Joint Commission, or CMS surveys, as required by supported service lines.
Current licensure appropriate for the degree held required.
CPR and de-escalation/restraint certification required; training is available upon hire and offered by the facility.
First aid may be required depending on state or facility.

Nice To Haves

Master’s degree in a behavioral health or risk discipline preferred.
Registered Nurse preferred.
One or more years of management experience preferred.

Responsibilities

Lead and monitor day-to-day regulatory readiness, patient safety, and service excellence across the facility.
Oversee and manage the QAPI program, including processes for identifying, collecting, and analyzing quality performance data.
Use outcome data to continuously improve services; prepare and evaluate the facility QAPI Program annually.
Complete process-improvement projects and incorporate results into patient-care improvements.
Submit quality scorecard data to the Acadia corporate office as requested.
Coordinate abstraction of clinical data according to Joint Commission specifications and data entry for Inpatient Psychiatric Core Measures, including measures such as HBIPS.
Aggregate relevant care indicators and feedback from consumers and collateral sources to improve management strategies and service delivery.
Lead and coordinate data collection and analysis from all facility departments.
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 monitoring processes, including facility-wide auditing and early identification of issues.
Collaborate with departments to implement regulatory and accreditation best practices and support measurable improvements in survey outcomes, patient safety, patient experience, and HBIPS.
Develop and maintain proficiency in regulatory planning for applicable local, state, and federal regulatory and accrediting bodies.
Develop and maintain proficiency in auditing electronic platforms, including electronic patient observations and the electronic medical record, as applicable.
Lead root-cause analyses and regularly evaluate serious incidents, complaints, grievances, and related investigations; identify patterns, submit findings and recommendations, and monitor actions and outcomes over time.
Develop corrective action plans with facility leaders to address regulatory vulnerabilities and patient-safety risks.
Ensure appropriate reporting of violations, potential violations, incidents, and adverse clinical outcomes to authorized enforcement or regulatory agencies.
In conjunction with the assigned corporate Division Quality Director, initiate and lead communications with regulatory agencies as appropriate.
Develop sustainable performance-improvement practices using data analysis and prioritization to improve survey readiness and consistency of care.
Promote multidisciplinary ownership of self-monitoring, auditing, and process improvement, escalating opportunities for improved engagement to the facility CEO as appropriate.
Ensure strategic and operational implementation of requirements, guidelines, and standards from federal, state, and local licensing agencies and accrediting and certifying organizations.
Collaborate with division and corporate entities and external parties to execute quality and patient-safety initiatives at the facility; communicate key performance-improvement activities to facility and division leadership.
Serve as a technical advisor, educator, and internal consultant on performance-improvement tools, analytical techniques, and statistical applications.
Ensure facility compliance with policies and applicable regulatory and accreditation standards.
Serve as the facility leader and subject-matter expert on high-reliability principles and strategies to achieve zero harm.
Assess clinical program fidelity, identify root causes of gaps, and support departments in developing remediation and improvement plans to meet Acadia practices and treatment-program requirements.
Develop, review, and provide education on internal clinical procedures and appropriate use of outcome-evaluation tools and results, including patient-experience data and quality scorecard metrics.
Translate standards, requirements, and policies into 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 and corrective actions to the Acadia corporate office.
Review incident and safety concerns with the leadership team to identify systemic issues and facilitate corrective actions.
Lead and facilitate root-cause analyses into all serious and/or sentinel events.
Support staff through hiring, development, training, performance management, and communication.
Oversee the Culture of Safety Survey and follow-up action planning and sustainment processes.
Identify actual or potential problems that pose risks to patients or staff and propose corrective steps, which may include policy or procedure changes, staffing or assignment changes, additional staff education or training, or changes to services.
Perform other functions and tasks as assigned.