Coachella Valley Behavioral Health
Director of Quality and PI
Coachella Valley Behavioral Health, Indio, California, United States, 92201
Located in Indio, California, Coachella Valley Behavioral Health is the only facility of its kind in the area, providing services for those in need of clinically excellent behavioral healthcare. The 80‑bed inpatient facility serves adults age 18 and older with mental health concerns and addictions, employing a holistic approach that addresses physical, social, and emotional factors.
We are seeking a dynamic and experienced Director of Quality and Accreditation to lead our facility’s efforts in ensuring the highest standards of patient care and safety. This leadership role is responsible for overseeing regulatory compliance, quality assurance programs, and continuous improvement initiatives across all clinical and operational areas. The Director will guide the development and implementation of quality protocols, manage accreditation processes, and lead the Quality Assurance and Process Improvement (QAPI) program. The ideal candidate will be a proactive, strategic thinker with a strong commitment to achieving excellence in care delivery and regulatory readiness.
Purpose Statement 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, regulations, and accreditation standards. The Director leads and oversees all aspects of policy development; comprehensive implementation of Acadia’s prescribed clinical protocols, operational quality oversight standards, and programmatic expectations; critical incident reporting; regulatory engagement, including development and submission of plans of correction; 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, and intentional sharing of deep subject‑matter expertise, the Director ensures a proactive, multidisciplinary focus on quality and excellence within the facility.
Compensation for this role will be between $108,000 and $135,000.
Essential Functions
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 collected data to drive continuous improvement of 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 abstraction of clinical data per Joint Commission specifications and enter via vendor database for Inpatient Psychiatric Core Measures (e.g., national quality measures such as HBIPS).
Identify key care indicators and evaluate data using formal and informal feedback from consumers and collateral sources 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 Governing Board.
Regulatory preparedness – implement sustainable survey preparation and ongoing monitoring processes, including facility‑wide auditing and early‑issue identification, to maximize achievement of zero‑ or standard‑level survey outcomes.
Facility‑wide support – collaborate with other departments to sustainably implement best practices in regulatory/accreditation compliance, evidenced by measurable results with regard to survey outcomes, patient safety metrics, patient experience results, HBIPS, etc.
Develop and maintain proficiency in regulatory planning strategy for all standards relevant to local, state, and federal regulatory and accrediting bodies.
Develop and maintain proficiency in the functionality and auditing within electronic platforms such as electronic patient observations and the electronic medical record.
Lead Root‑Cause Analyses and conduct timely and regular evaluation of serious incidents, complaints, grievances, and related investigations to identify events, trends, and patterns that may affect client health, safety, or treatment efficacy; compile findings and recommendations for corrective action; analyze outcomes over time; and develop corrective action plans.
Ensure proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and required.
In conjunction with the assigned corporate Division Quality Director, initiate and lead communications with regulatory agencies as appropriate.
Develop sustainable performance improvement practices through data analysis and prioritization to improve survey readiness and consistency of care delivery using best‑practices.
Ensure multidisciplinary ownership of best practices in self‑monitoring, auditing, and process improvement; elevate opportunities for improved engagement to the facility CEO as appropriate.
Ensure strategic and operational implementation of regulatory requirements, guidelines, and standards of federal, state, and local licensing agencies, accrediting and certifying organizations.
Collaborate with division and corporate entities and external parties to ensure strategic quality and patient safety initiatives are fully executed at the facility level; facilitate effective communication with facility and division leadership regarding key clinical performance improvement activities.
Serve as a technical advisor, educator, and internal consultant to all hospital management, staff, and physicians on the use of performance improvement tools, analytical techniques, and statistical applications.
Ensure facility compliance with policies and applicable standards as required by regulatory/accrediting bodies.
Act as facility leader and subject‑matter expert on high reliability principles and strategies to achieve zero harm.
Clinical program excellence – assess fidelity and identify root causes for gaps or lapses in fidelity to Acadia standards; support other departments in developing and implementing remediation and improvement plans to achieve fidelity to Acadia’s expected practices, including all elements of treatment program implementation.
Develop, review, and educate on internal clinical procedures and appropriate use of outcome evaluation tools and the associated results – including patient experience data and other quality scorecard metrics – to ensure continuous quality improvement and ongoing compliance with federal, state, and third‑party regulatory requirements.
Translate standards, requirements, and policies into terms or processes meaningful to the facility.
Chair the monthly Quality Council.
Complete safety rounds, participate in leadership rounding, and submit results/corrective actions to Acadia corporate office.
Review incident/safety concerns with the leadership team to identify systemic issues and facilitate the development of corrective actions.
Lead and facilitate Root Cause Analyses into all serious and/or sentinel events.
Invest in the facility staff through engagement in hiring, development, training, performance management, and communication to ensure effective and efficient operations.
Oversee the Culture of Safety Survey and follow‑up action planning and sustainment processes.
Identify problems or potential problems to prevent risks to patients and staff; propose corrective steps, including changes in policies/procedures, staffing assignments, additional education or training for staff, or addition/delete of services.
Education, Experience, and Skill Requirements
Bachelor’s Degree in Human Services or nursing required; Master’s degree in behavioral health or 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 service line(s) supported.
Licenses, Designations, and Certifications
Current licensure appropriate for the degree held required.
CPR and de‑escalation/restraint certification required (training available upon hire and offered by facility).
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.
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We are seeking a dynamic and experienced Director of Quality and Accreditation to lead our facility’s efforts in ensuring the highest standards of patient care and safety. This leadership role is responsible for overseeing regulatory compliance, quality assurance programs, and continuous improvement initiatives across all clinical and operational areas. The Director will guide the development and implementation of quality protocols, manage accreditation processes, and lead the Quality Assurance and Process Improvement (QAPI) program. The ideal candidate will be a proactive, strategic thinker with a strong commitment to achieving excellence in care delivery and regulatory readiness.
Purpose Statement 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, regulations, and accreditation standards. The Director leads and oversees all aspects of policy development; comprehensive implementation of Acadia’s prescribed clinical protocols, operational quality oversight standards, and programmatic expectations; critical incident reporting; regulatory engagement, including development and submission of plans of correction; 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, and intentional sharing of deep subject‑matter expertise, the Director ensures a proactive, multidisciplinary focus on quality and excellence within the facility.
Compensation for this role will be between $108,000 and $135,000.
Essential Functions
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 collected data to drive continuous improvement of 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 abstraction of clinical data per Joint Commission specifications and enter via vendor database for Inpatient Psychiatric Core Measures (e.g., national quality measures such as HBIPS).
Identify key care indicators and evaluate data using formal and informal feedback from consumers and collateral sources 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 Governing Board.
Regulatory preparedness – implement sustainable survey preparation and ongoing monitoring processes, including facility‑wide auditing and early‑issue identification, to maximize achievement of zero‑ or standard‑level survey outcomes.
Facility‑wide support – collaborate with other departments to sustainably implement best practices in regulatory/accreditation compliance, evidenced by measurable results with regard to survey outcomes, patient safety metrics, patient experience results, HBIPS, etc.
Develop and maintain proficiency in regulatory planning strategy for all standards relevant to local, state, and federal regulatory and accrediting bodies.
Develop and maintain proficiency in the functionality and auditing within electronic platforms such as electronic patient observations and the electronic medical record.
Lead Root‑Cause Analyses and conduct timely and regular evaluation of serious incidents, complaints, grievances, and related investigations to identify events, trends, and patterns that may affect client health, safety, or treatment efficacy; compile findings and recommendations for corrective action; analyze outcomes over time; and develop corrective action plans.
Ensure proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and required.
In conjunction with the assigned corporate Division Quality Director, initiate and lead communications with regulatory agencies as appropriate.
Develop sustainable performance improvement practices through data analysis and prioritization to improve survey readiness and consistency of care delivery using best‑practices.
Ensure multidisciplinary ownership of best practices in self‑monitoring, auditing, and process improvement; elevate opportunities for improved engagement to the facility CEO as appropriate.
Ensure strategic and operational implementation of regulatory requirements, guidelines, and standards of federal, state, and local licensing agencies, accrediting and certifying organizations.
Collaborate with division and corporate entities and external parties to ensure strategic quality and patient safety initiatives are fully executed at the facility level; facilitate effective communication with facility and division leadership regarding key clinical performance improvement activities.
Serve as a technical advisor, educator, and internal consultant to all hospital management, staff, and physicians on the use of performance improvement tools, analytical techniques, and statistical applications.
Ensure facility compliance with policies and applicable standards as required by regulatory/accrediting bodies.
Act as facility leader and subject‑matter expert on high reliability principles and strategies to achieve zero harm.
Clinical program excellence – assess fidelity and identify root causes for gaps or lapses in fidelity to Acadia standards; support other departments in developing and implementing remediation and improvement plans to achieve fidelity to Acadia’s expected practices, including all elements of treatment program implementation.
Develop, review, and educate on internal clinical procedures and appropriate use of outcome evaluation tools and the associated results – including patient experience data and other quality scorecard metrics – to ensure continuous quality improvement and ongoing compliance with federal, state, and third‑party regulatory requirements.
Translate standards, requirements, and policies into terms or processes meaningful to the facility.
Chair the monthly Quality Council.
Complete safety rounds, participate in leadership rounding, and submit results/corrective actions to Acadia corporate office.
Review incident/safety concerns with the leadership team to identify systemic issues and facilitate the development of corrective actions.
Lead and facilitate Root Cause Analyses into all serious and/or sentinel events.
Invest in the facility staff through engagement in hiring, development, training, performance management, and communication to ensure effective and efficient operations.
Oversee the Culture of Safety Survey and follow‑up action planning and sustainment processes.
Identify problems or potential problems to prevent risks to patients and staff; propose corrective steps, including changes in policies/procedures, staffing assignments, additional education or training for staff, or addition/delete of services.
Education, Experience, and Skill Requirements
Bachelor’s Degree in Human Services or nursing required; Master’s degree in behavioral health or 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 service line(s) supported.
Licenses, Designations, and Certifications
Current licensure appropriate for the degree held required.
CPR and de‑escalation/restraint certification required (training available upon hire and offered by facility).
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.
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