Quality Improvement Director

Kitsap Mental Health Services•Bremerton, WA
•$107,910 - $137,592•Onsite

About The Position

Kitsap Mental Health Services (KMHS) is seeking a Quality Improvement Director to lead the agency's quality improvement program and accreditation readiness efforts. This position helps ensure clinical and operational practices meet regulatory expectations and support high-quality care. This role uses data to identify improvement opportunities and guide organizational decision-making. If you're committed to improving systems that support quality care and organizational accountability, we welcome your application.

Requirements

  • Bachelor’s degree in nursing, social work, psychology, behavioral health, healthcare administration, public health, quality improvement, or related subject.
  • Seven (7) or more years of progressively responsible job experience in healthcare quality improvement, behavioral health administration, regulatory compliance, or program evaluation.
  • Experience supporting accreditation, regulatory, or patient safety initiatives.
  • Four or more years of experience working in a healthcare setting, including hospitals, ambulatory care, community health, or managed care environments.
  • Experience managing organizational risk and liability issues.
  • Three years of management or supervisory experience.
  • Knowledge of applicable clinical principles and practices.
  • High-level knowledge of HIPAA and HITECH security regulations and other confidentiality and health information protections and their impacts in the clinical practice setting.
  • Working knowledge of legal statutes and quality improvement strategies that govern clinical skills, clinical documentation, and agency operations.
  • Federal, state, and local regulations in the behavioral healthcare field.
  • Familiarity with the Diagnostic and Statistical Manual, fifth edition (DSM-5) of Mental Health Disorders, the ASAM Criteria, and quality improvement processes at a systemic level.
  • Excellent communication and skill in establishing and maintaining effective working relationships with other employees, patients, organizations, and the public.
  • Confidentiality, diplomacy, and judgment in sensitive situations.
  • Guide individuals and groups toward desired outcomes, setting high-performance standards and delivering leading quality services.
  • Use adaptive leadership and a systems approach to implement effective, organization‑wide improvements.
  • Establish and maintain long-term relationships with both internal and external customers, building trust and respect by consistently meeting and exceeding expectations. Ability to anticipate concerns and overcome objections.
  • Articulate knowledge and understanding of organizational policies, procedures, and systems.
  • Proficient in Microsoft Office applications and the ability to navigate an EMR system and other applications as required with minimal training.

Nice To Haves

  • Master’s degree in nursing, social work, psychology, behavioral health, healthcare administration, public health, quality improvement, or related subject.
  • Certified Professional in Healthcare Quality (CPHQ).
  • Formal Project Management training or certification.

Responsibilities

  • Provide leadership and support in establishing and directing the Quality Improvement Program consistent with all regulatory requirements.
  • Develop and execute a comprehensive quality strategy that advances clinical excellence, client safety, recovery-oriented care, health equity, population health, and measurable outcomes.
  • Lead the evaluation of care-delivery models and collaborate with clinical and operations teams to identify opportunities, implement evidence-based improvements, and sustain high-quality services across the organization.
  • Lead the development of key performance indicators, outcomes measures, data-collection methods, benchmarks, and reporting structures used to monitor clinical quality, regulatory compliance, client experience, and organizational performance.
  • Guide multidisciplinary teams in testing, evaluating, scaling and sustaining changes that improve workflows, clinical outcomes, access to services, care coordination, and client experience.
  • Collaborate closely with the Compliance Director to lead organizational readiness for CARF accreditation, DOH licensing, certifications, contractual, and all other external audit requirements.
  • Direct gap analyses, mock reviews, corrective action plans, and improvement activities to ensure alignment with organizational policies, applicable quality standards, state regulations, and other requirements.
  • Develop executive-level reports, dashboards, presentations, and recommendations that translate complex findings into clear, actionable insights for clinical, operational, and governance audiences.
  • Work collaboratively with leaders across the organization to support quality improvement, population health, and health equity initiatives.
  • Build organizational capability improvement by coaching leaders and staff, facilitating multidisciplinary teams, and providing education on measurement and process improvement.
  • Employ Plan-Do-Study-Act cycles (PDSAs) and other improvement methods to evaluate and strengthen organizational workflows.
  • Promote understanding and adoption of evidence-based and data-driven best practices throughout the agency.
  • Analyze processes, policies, and systems to ensure continued alignment with regulatory requirements and accreditation standards.
  • Lead the dissemination of quality improvement information and performance data to leadership and committees.
  • Communicate quality goals, improvement priorities, and performance results to employees across the organization.
  • Plan and facilitate quality committee meetings and ensure timely follow-up on action items and improvement activities.
  • Participate in evaluations and audits and develop associated action plans and quality improvement objectives.
  • Maintain current knowledge of regulatory requirements associated with the Quality Improvement Program.
  • Oversee the Community Advisory Council and communicate quality improvement recommendations and community feedback to KMHS Leadership and the Board of Directors.
  • Hire, train, coach, and supervise quality improvement staff.
  • Collaborate with the Chief Compliance and Privacy Officer in the annual performance review process.

Benefits

  • Health, Dental & Vision
  • Generous PTO: Up to 19 days + 2 mental health days + 10 holidays (pro-rated for part-time)
  • Fully Paid YMCA Membership for you and eligible family members
  • Company-Paid Life & Disability Insurance
  • Student Loan Assistance & Professional Development
  • 403(b) Retirement Plan with Company Contributions
  • Employee Assistance Program (EAP)
  • Pet Insurance
  • Free Wellness App (2MorrowHealth)
  • Collaborative, Supportive Team Environment
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