Capitol Park Mental Health Hospital
Director of Quality and Accreditation
Capitol Park Mental Health Hospital, Saint Paul, Minnesota, United States, 55199
Overview
Acadia Healthcare is a leading provider of behavioral healthcare services across the United States. Acadia operates a growing network of 250 plus behavioral healthcare facilities with approximately 11,100 beds in 39 states and Puerto Rico. With more than 23,000 employees serving approximately 75,000 patients daily, Acadia is the largest stand-alone behavioral health company in the U.S. Acadia’s purpose is to Lead Care With Light and its mission is to be a world-class organization that sets the standard for excellence in the treatment of mental health and addiction concerns. Opened in September 2025, Capitol Park Mental Health Hospital is a 144-bed facility offering inpatient, intensive outpatient and partial hospitalization mental health treatment. Position
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. The Director leads and oversees policy development, implementation of protocol and quality standards, incident reporting, regulatory engagement, certification achievement and maintenance, oversight of the quality assurance and process improvement (QAPI) program, and ongoing regulatory readiness strategies at the facility. Through routine presence in patient care areas, data analysis, and documentation monitoring, the Director ensures a proactive, multidisciplinary focus on quality and excellence within the facility. Responsibilities
Lead and monitor day-to-day regulatory readiness, patient safety, and service excellence across the facility. QAPI program oversight and management — develop processes for identification, collection, and analysis of quality performance data; utilize data to deliver continuously improving services. Conduct annual preparation and evaluation of the facility QAPI Program; complete process improvement projects and incorporate 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 and data entry via vendor database for Inpatient Psychiatric Core Measures (e.g., HBIPS). Identify key care indicators and evaluate data using formal and informal feedback to improve management strategies and service delivery practices. Lead/coordinate data collection and analysis from all departments within the facility; prepare and present program data trends and action plans to the monthly Quality Council and quarterly to the Medical Executive Committee and the Governing Board. Regulatory preparedness — implement sustainable survey preparation and ongoing monitoring processes, including facility-wide auditing and early issue identification, to maximize survey outcomes. Facility-wide support — collaborate with other departments to sustainably implement best-practices in regulatory/accreditation compliance as evidenced by measurable results in survey outcomes, patient safety metrics, and patient experience results. Develop and maintain proficiency in regulatory planning for all standards across local, state, and federal levels; maintain proficiency in electronic platforms such as electronic observations and electronic medical records as applicable. Lead Root Cause Analyses and evaluate serious incidents, complaints, grievances, and investigations, identifying events, trends, and corrective actions to improve patient health and safety. Develop corrective action plans for regulatory vulnerabilities in collaboration with facility leaders. Ensure proper reporting of violations to appropriate enforcement agencies as required. Lead communications with regulatory agencies as appropriate in conjunction with the corporate Division Quality Director. Develop sustainable performance improvement practices to improve survey readiness and consistency of care delivery using best-practice methods. Ensure multidisciplinary ownership of self-monitoring, auditing, and process improvement, escalating opportunities for improved engagement to the facility CEO as appropriate. Ensure compliance with federal, state, and local licensing agencies, accrediting and certifying organizations; collaborate with Division and Corporate to execute quality and patient safety initiatives at the facility level. Serve as a technical advisor, educator, and internal consultant on performance improvement tools, analytical techniques, and statistical applications. Ensure facility compliance with applicable policies and standards; act as a leader and subject matter expert on high reliability principles to achieve zero harm. Clinical program excellence — assess fidelity, identify root causes for gaps, and support remediation and improvement plans to achieve fidelity to Acadia’s practices, including all elements of treatment program implementation; educate on internal clinical procedures and use of outcome evaluation tools to ensure continuous quality improvement and regulatory compliance. Translate standards and policies into meaningful facility processes. Leadership — chair the monthly Quality Council, participate in safety and leadership rounds, review incident/safety concerns, lead Root Cause Analyses, and oversee hiring, development, training, performance management, and communication to ensure effective operations. Qualifications
Bachelor’s Degree in Human Services or Nursing required. Master’s degree in behavioral health/risk discipline or RN preferred. Two or more years of experience in a Quality, Clinical, or PI role; one or more years of management experience preferred. Experience with CARF, DEA, Joint Commission, or CMS surveys as required by the service lines supported. Current licensure appropriate for the degree held; CPR and de-escalation/restraint certification required; First aid may be required depending on state or facility. Additional Information
We are committed to providing equal employment opportunities to all applicants for employment regardless of characteristics protected by applicable laws. Management reserves the right to add or remove duties as circumstances dictate. We are unable to locate this position at the moment; if you are viewing this description, please note that it reflects the responsibilities and qualifications for the role as described by the employer. Referrals may increase your chances of securing an interview.
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Acadia Healthcare is a leading provider of behavioral healthcare services across the United States. Acadia operates a growing network of 250 plus behavioral healthcare facilities with approximately 11,100 beds in 39 states and Puerto Rico. With more than 23,000 employees serving approximately 75,000 patients daily, Acadia is the largest stand-alone behavioral health company in the U.S. Acadia’s purpose is to Lead Care With Light and its mission is to be a world-class organization that sets the standard for excellence in the treatment of mental health and addiction concerns. Opened in September 2025, Capitol Park Mental Health Hospital is a 144-bed facility offering inpatient, intensive outpatient and partial hospitalization mental health treatment. Position
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. The Director leads and oversees policy development, implementation of protocol and quality standards, incident reporting, regulatory engagement, certification achievement and maintenance, oversight of the quality assurance and process improvement (QAPI) program, and ongoing regulatory readiness strategies at the facility. Through routine presence in patient care areas, data analysis, and documentation monitoring, the Director ensures a proactive, multidisciplinary focus on quality and excellence within the facility. Responsibilities
Lead and monitor day-to-day regulatory readiness, patient safety, and service excellence across the facility. QAPI program oversight and management — develop processes for identification, collection, and analysis of quality performance data; utilize data to deliver continuously improving services. Conduct annual preparation and evaluation of the facility QAPI Program; complete process improvement projects and incorporate 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 and data entry via vendor database for Inpatient Psychiatric Core Measures (e.g., HBIPS). Identify key care indicators and evaluate data using formal and informal feedback to improve management strategies and service delivery practices. Lead/coordinate data collection and analysis from all departments within the facility; prepare and present program data trends and action plans to the monthly Quality Council and quarterly to the Medical Executive Committee and the Governing Board. Regulatory preparedness — implement sustainable survey preparation and ongoing monitoring processes, including facility-wide auditing and early issue identification, to maximize survey outcomes. Facility-wide support — collaborate with other departments to sustainably implement best-practices in regulatory/accreditation compliance as evidenced by measurable results in survey outcomes, patient safety metrics, and patient experience results. Develop and maintain proficiency in regulatory planning for all standards across local, state, and federal levels; maintain proficiency in electronic platforms such as electronic observations and electronic medical records as applicable. Lead Root Cause Analyses and evaluate serious incidents, complaints, grievances, and investigations, identifying events, trends, and corrective actions to improve patient health and safety. Develop corrective action plans for regulatory vulnerabilities in collaboration with facility leaders. Ensure proper reporting of violations to appropriate enforcement agencies as required. Lead communications with regulatory agencies as appropriate in conjunction with the corporate Division Quality Director. Develop sustainable performance improvement practices to improve survey readiness and consistency of care delivery using best-practice methods. Ensure multidisciplinary ownership of self-monitoring, auditing, and process improvement, escalating opportunities for improved engagement to the facility CEO as appropriate. Ensure compliance with federal, state, and local licensing agencies, accrediting and certifying organizations; collaborate with Division and Corporate to execute quality and patient safety initiatives at the facility level. Serve as a technical advisor, educator, and internal consultant on performance improvement tools, analytical techniques, and statistical applications. Ensure facility compliance with applicable policies and standards; act as a leader and subject matter expert on high reliability principles to achieve zero harm. Clinical program excellence — assess fidelity, identify root causes for gaps, and support remediation and improvement plans to achieve fidelity to Acadia’s practices, including all elements of treatment program implementation; educate on internal clinical procedures and use of outcome evaluation tools to ensure continuous quality improvement and regulatory compliance. Translate standards and policies into meaningful facility processes. Leadership — chair the monthly Quality Council, participate in safety and leadership rounds, review incident/safety concerns, lead Root Cause Analyses, and oversee hiring, development, training, performance management, and communication to ensure effective operations. Qualifications
Bachelor’s Degree in Human Services or Nursing required. Master’s degree in behavioral health/risk discipline or RN preferred. Two or more years of experience in a Quality, Clinical, or PI role; one or more years of management experience preferred. Experience with CARF, DEA, Joint Commission, or CMS surveys as required by the service lines supported. Current licensure appropriate for the degree held; CPR and de-escalation/restraint certification required; First aid may be required depending on state or facility. Additional Information
We are committed to providing equal employment opportunities to all applicants for employment regardless of characteristics protected by applicable laws. Management reserves the right to add or remove duties as circumstances dictate. We are unable to locate this position at the moment; if you are viewing this description, please note that it reflects the responsibilities and qualifications for the role as described by the employer. Referrals may increase your chances of securing an interview.
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