Director of Quality Assurance, Process Improvement, and Patient Safety - Behavioral Health

Summit BHC

2d•Remote

About The Position

PURPOSE STATEMENT: The Director-QAPI & Patient Safety leads and coordinates quality and performance improvement, regulatory compliance, and patient safety efforts across multiple behavioral healthcare sites. This role ensures that all programs operate within federal, state, and accreditation standards, while driving a culture of continuous improvement, clinical excellence, and risk reduction.

Requirements

Bachelor’s Degree in Nursing, Behavioral Health or related field required.
Four or more years’ experience in healthcare quality, patient safety, or risk management.
Experience in behavioral health setting and multi-site operations required.
Deep knowledge of QAPI frameworks (e.g. PDCA).
Familiarity with behavioral health accreditation and regulatory requirements.
Strong data analysis skills including proficiency with quality software/tools, Excel, Power BI, HC analytics.
Ability to travel between sites regularly (75%-90%).
Occasional evenings/weekends for audits, training, or investigations.

Nice To Haves

Masters’ Degree (MPH, MSN, MHA, MSW or related) preferred.
Certified Professional in Healthcare Quality (CPHQ) or Patient Safety (CPPS) preferred.
Two or more years’ supervisory/management experience preferred.

Responsibilities

Identifies, assesses, and prioritizes facilities in the areas of quality, risk, and patient safety.
Completes onsite visits to each assigned facility routinely a minimum of once per quarter and more frequently for higher risk, problem prone facilities.
Conducts weekly calls with each assigned facility for communication and collaboration, and to review Smart Sheets,
Completes required reports such as Weekly Risk Report, Facility Smart Sheets, and other internal documents as requested.
Attends and participates in scheduled weekly, biweekly, monthly, and quarterly meetings on camera or in-person.
Become familiar with each assigned facility’s State licensing and reporting requirements.
Interviews, onboards and conducts weekly 1:1 supervision to facility Quality and Risk Directors.
Participates in relevant start-up facility processes and readiness for licensing and accreditation.
Ensures facility QAPI programs are aligned with strategic goals.
Collects, analyzes, and reports key performance indicators (KPIs), dashboards, and outcome metrics.
Lead root cause analyses (RCAs), failure mode and effects analyses (FMEAs), and other process evaluations.
Collaborates with leadership and clinical teams to identify opportunities for improvement and develop action plans.
Facilitates quality improvement (QI) committees and promote cross-site collaboration and learning.
Lead the development and implementation of patient safety initiatives to reduce harm and improve outcomes.
Oversees incident reporting processes and conduct trend analysis for adverse events, near misses, and sentinel events.
Ensures follow-up and closure of safety-related investigations, including documentation and communication of lessons learned.
Works in partnership with quality, operations, and clinical leadership to mitigate risks and implement corrective actions.
Monitors the timely submission and escalation of both internal and external reporting of adverse events, as well as plans of correction.
Ensures all programs maintain compliance with applicable standards (e.g., Joint Commission, CARF, SAMHSA) and State requirements.
Coordinates and aids with external audits, surveys, and regulatory visits.
Monitors changes in regulatory requirements and implement policy/procedural updates as needed.
Assists with policy development and standard operating procedures to ensure standardization across sites.
Assists facilities with development and implementation of corrective action plans, evidence of standards compliance and other required submissions following mock and actual surveys.
Supports and mentors site-level Quality staff.
Conducts multisite, multidisciplinary leadership calls.
Serves as a key advisor to facility leadership on quality and safety strategy.
Champions a just culture and foster a system of accountability and learning.
Supports integration of evidence-based practices across disciplines and service lines.