Director of Quality and Accreditation

Acadia•Detroit, MI

About The Position

The Director of Quality and Accreditation leads facility-wide efforts to ensure patient safety, superior quality of care, regulatory compliance, survey readiness, treatment-program fidelity, and adherence to state and federal laws and accreditation standards. The role oversees policy development; implementation of clinical protocols, operational quality standards, and program expectations; critical-incident reporting; regulatory engagement and plans of correction; certification; and the Quality Assurance and Process Improvement (QAPI) program. Through presence in patient-care areas, data analysis, documentation monitoring, and sharing subject-matter expertise, the Director promotes a proactive, multidisciplinary focus on quality and excellence. The Director leads regulatory readiness and continuous improvement across clinical and operational areas, develops and evaluates quality processes, and uses performance data to improve services and patient care. The role coordinates clinical-data abstraction for Joint Commission measures and reporting, aggregates feedback and indicators, and presents trends and action plans to facility committees and governing bodies. The Director also leads audits, incident investigations and Root Cause Analyses, develops corrective actions, and works with facility, division, corporate, and external partners to sustain compliance and improve outcomes. As a visible member of the facility leadership team, the Director chairs the monthly Quality Council, participates in safety and leadership rounds, advises and educates staff and physicians on performance-improvement methods, and supports staff hiring, development, training, and performance management. A bachelor’s degree in Human Services or nursing and current licensure appropriate to the degree are required. A master’s degree in behavioral health or a risk discipline, Registered Nurse status, and management experience are preferred. At least two years of experience in a Quality, Clinical, or PI role is required; experience with applicable CARF, DEA, Joint Commission, or CMS surveys is also required as relevant to the supported service line. CPR and de-escalation/restraint certification are required, with training available upon hire and offered by the facility. First aid may be required depending on the state or facility.

Requirements

Bachelor’s degree in Human Services or nursing.
At least two years of experience in a Quality, Clinical, or PI role.
Experience with CARF, DEA, Joint Commission, or CMS surveys, as required by the supported service line.
Current licensure appropriate for the degree held.
CPR and de-escalation/restraint certification; training is available upon hire and offered by the facility.

Nice To Haves

Master’s degree in a behavioral health or risk discipline.
Registered Nurse status.
One or more years of management experience.
First aid, which may be required depending on the 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, including processes for identifying, collecting, and analyzing quality performance data.
Use outcome data to continuously improve services and complete process-improvement projects that inform patient-care improvements.
Conduct annual preparation and evaluation of the facility QAPI Program and submit quality scorecard data to the Acadia corporate office as requested.
Coordinate abstraction of clinical data according to Joint Commission specifications and entry of Inpatient Psychiatric Core Measures data into the vendor database.
Aggregate relevant care indicators and feedback from service consumers and other sources to improve management strategies and service delivery.
Lead and coordinate data collection and analysis across facility departments.
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 improve survey outcomes, patient-safety metrics, patient experience results, and HBIPS measures.
Maintain proficiency in regulatory planning for applicable local, state, and federal standards and in auditing relevant electronic platforms, including electronic patient-observation systems and electronic medical records.
Lead Root Cause Analyses and regularly evaluate serious incidents, complaints, grievances, and related investigations; identify trends, submit findings and recommendations, and analyze implemented actions and outcomes over time.
Develop corrective-action plans with facility leaders to address regulatory vulnerabilities and risks to patient safety.
Ensure appropriate reporting of violations, potential violations, incidents, and adverse clinical outcomes to authorized enforcement or regulatory agencies.
Initiate and lead communications with regulatory agencies in conjunction with the assigned corporate Division Quality Director, 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 engagement opportunities to the facility CEO as appropriate.
Ensure implementation of federal, state, and local regulatory requirements, guidelines, and standards, and collaborate with division, corporate, and external partners on quality and patient-safety initiatives.
Advise, educate, and consult with hospital management, staff, and physicians on performance-improvement tools, analytical techniques, and statistical applications.
Ensure facility compliance with policies and applicable regulatory and accreditation standards.
Assess clinical-program fidelity, identify root causes of gaps, and support remediation and improvement plans to meet Acadia practices and treatment-program expectations.
Develop, review, and educate staff on internal clinical procedures and the use of outcome-evaluation tools and results, including patient-experience and quality-scorecard metrics.
Serve as a visible, engaged member of the facility leadership team and 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 leadership, identify systemic issues, and facilitate corrective actions.
Lead and facilitate Root Cause Analyses into all serious and/or sentinel events.
Engage in staff hiring, development, training, performance management, and communication to support effective operations.
Oversee the Culture of Safety Survey and follow-up action planning and sustainment.
Identify actual or potential risks to patients and staff and propose corrective steps, which may include policy or procedure changes, staffing or assignment changes, additional staff education or training, and changes to services.
Perform other functions and tasks as assigned.