Capitol Park Mental Health Hospital
Director of Quality and Accreditation
Capitol Park Mental Health Hospital, Saint Paul, Minnesota, United States, 55199
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Director of Quality and Accreditation
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Capitol Park Mental Health Hospital
Overview Acadia Healthcare, the largest stand‑alone behavioral health company in the U.S., operates a network of over 250 facilities in 39 states and Puerto Rico. Their mission is to lead care with light and set the standard for excellence in mental health and addiction treatment. The Capitol Park Mental Health Hospital, a 144‑bed facility opened in September 2025, will provide inpatient, intensive outpatient and partial hospitalization services. The Director of Quality and Accreditation ensures patient safety and superior quality of care through survey readiness, treatment program fidelity, and compliance with state, federal, and accreditation standards.
Responsibilities
Lead and monitor day‑to‑day regulatory readiness, patient safety, and service excellence across the facility.
Oversee the QAPI program: develop processes for collecting, analyzing, and using quality performance data; conduct annual QAPI evaluations; complete improvement projects and submit scorecard data to Acadia corporate office.
Coordinate data collection and analysis from all departments; prepare and present program data trends and action plans to the monthly Quality Council, quarterly Medical Executive Committee, and Governing Board.
Implement sustainable survey preparation and ongoing monitoring processes, including facility‑wide audits and early‑issue identification, to achieve zero‑ or standard‑level survey outcomes.
Develop and maintain regulatory planning strategy for all relevant bodies (local, state, federal); audit electronic platforms such as patient observations and EMR; lead root‑cause analyses and serious incident investigations.
Develop corrective action plans, report violations to authorized enforcement agencies, and maintain multidisciplinary ownership of best practices in self‑monitoring, auditing, and process improvement.
Serve as a technical advisor, educator, and consultant on performance improvement tools, analytical techniques, and statistical applications.
Ensure compliance with policies and applicable standards; act as the facility’s subject matter expert on high reliability principles and zero‑harm strategies.
Assess fidelity and identify root causes for gaps in Acadia standards; support remediation and improvement plans across clinical programs.
Lead the facility leadership team: chair the monthly Quality Council, complete safety rounds, facilitate root‑cause analyses, and engage staff in hiring, training, and performance management.
Perform other functions and tasks as assigned.
Qualifications
Bachelor’s Degree in Human Services or Nursing required. Master’s degree in behavioral health/risk discipline or Registered Nurse preferred.
Two or more years of experience in a Quality, Clinical, or PI role required.
One or more years of management experience preferred.
Experience with CARF, DEA, Joint Commission, or CMS surveys as required by supported service lines.
Licenses/Designations/Certifications
Current licensure appropriate for the degree held required.
CPR and de‑escalation/restraint certification required (training available upon hire).
First aid may be required based on state or facility.
Additional Regulatory Requirements While this job description is intended to be an accurate reflection of the requirements of the job, management reserves the right to add or remove duties from particular jobs when circumstances (e.g., emergencies, changes in workload, rush jobs or technological developments) dictate.
We are committed to providing equal employment opportunities to all applicants for employment regardless of an individual’s characteristics protected by applicable state, federal, and local laws.
Seniority level: Director
Employment type: Full‑time
Job function: Quality Assurance
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Director of Quality and Accreditation
role at
Capitol Park Mental Health Hospital
Overview Acadia Healthcare, the largest stand‑alone behavioral health company in the U.S., operates a network of over 250 facilities in 39 states and Puerto Rico. Their mission is to lead care with light and set the standard for excellence in mental health and addiction treatment. The Capitol Park Mental Health Hospital, a 144‑bed facility opened in September 2025, will provide inpatient, intensive outpatient and partial hospitalization services. The Director of Quality and Accreditation ensures patient safety and superior quality of care through survey readiness, treatment program fidelity, and compliance with state, federal, and accreditation standards.
Responsibilities
Lead and monitor day‑to‑day regulatory readiness, patient safety, and service excellence across the facility.
Oversee the QAPI program: develop processes for collecting, analyzing, and using quality performance data; conduct annual QAPI evaluations; complete improvement projects and submit scorecard data to Acadia corporate office.
Coordinate data collection and analysis from all departments; prepare and present program data trends and action plans to the monthly Quality Council, quarterly Medical Executive Committee, and Governing Board.
Implement sustainable survey preparation and ongoing monitoring processes, including facility‑wide audits and early‑issue identification, to achieve zero‑ or standard‑level survey outcomes.
Develop and maintain regulatory planning strategy for all relevant bodies (local, state, federal); audit electronic platforms such as patient observations and EMR; lead root‑cause analyses and serious incident investigations.
Develop corrective action plans, report violations to authorized enforcement agencies, and maintain multidisciplinary ownership of best practices in self‑monitoring, auditing, and process improvement.
Serve as a technical advisor, educator, and consultant on performance improvement tools, analytical techniques, and statistical applications.
Ensure compliance with policies and applicable standards; act as the facility’s subject matter expert on high reliability principles and zero‑harm strategies.
Assess fidelity and identify root causes for gaps in Acadia standards; support remediation and improvement plans across clinical programs.
Lead the facility leadership team: chair the monthly Quality Council, complete safety rounds, facilitate root‑cause analyses, and engage staff in hiring, training, and performance management.
Perform other functions and tasks as assigned.
Qualifications
Bachelor’s Degree in Human Services or Nursing required. Master’s degree in behavioral health/risk discipline or Registered Nurse preferred.
Two or more years of experience in a Quality, Clinical, or PI role required.
One or more years of management experience preferred.
Experience with CARF, DEA, Joint Commission, or CMS surveys as required by supported service lines.
Licenses/Designations/Certifications
Current licensure appropriate for the degree held required.
CPR and de‑escalation/restraint certification required (training available upon hire).
First aid may be required based on state or facility.
Additional Regulatory Requirements While this job description is intended to be an accurate reflection of the requirements of the job, management reserves the right to add or remove duties from particular jobs when circumstances (e.g., emergencies, changes in workload, rush jobs or technological developments) dictate.
We are committed to providing equal employment opportunities to all applicants for employment regardless of an individual’s characteristics protected by applicable state, federal, and local laws.
Seniority level: Director
Employment type: Full‑time
Job function: Quality Assurance
#J-18808-Ljbffr