Acadia Healthcare
Director of Quality and Accreditation
Acadia Healthcare, Saint Paul, Minnesota, United States, 55102
Director Of Quality And Accreditation
Opening in Fall 2025, Capitol Park Mental Health Hospital, 144-bed, located at the former site of Bethesda Hospital, will offer inpatient, intensive outpatient and "partial hospitalization" mental health treatment. 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. As such, the Director is responsible for leading and overseeing 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 on-going regulatory readiness strategies at the facility. Through routine physical presence in patient care areas, data analysis and documentation monitoring, and intentional sharing of deep subject-matter expertise, the Director will ensure a proactive, multidisciplinary focus on quality and excellence within the facility. Essential Functions: Lead and monitor day-to-day regulatory readiness, patient safety, and service excellence across the facility. QAPI program oversight and management
follow and develop processes for identification, collection, and analysis of quality performance data. 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. Clinical program excellence
assess fidelity and identify root-causes for gaps/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. Leadership
serve as a visible, engaged, and dynamic member of the facility leadership team. Other Functions: Perform other functions and tasks as assigned. Education/Experience/Skill Requirements: Bachelor's Degree in Human Services or nursing required. Master's degree in behavioral health/risk discipline, 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/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 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.
Opening in Fall 2025, Capitol Park Mental Health Hospital, 144-bed, located at the former site of Bethesda Hospital, will offer inpatient, intensive outpatient and "partial hospitalization" mental health treatment. 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. As such, the Director is responsible for leading and overseeing 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 on-going regulatory readiness strategies at the facility. Through routine physical presence in patient care areas, data analysis and documentation monitoring, and intentional sharing of deep subject-matter expertise, the Director will ensure a proactive, multidisciplinary focus on quality and excellence within the facility. Essential Functions: Lead and monitor day-to-day regulatory readiness, patient safety, and service excellence across the facility. QAPI program oversight and management
follow and develop processes for identification, collection, and analysis of quality performance data. 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. Clinical program excellence
assess fidelity and identify root-causes for gaps/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. Leadership
serve as a visible, engaged, and dynamic member of the facility leadership team. Other Functions: Perform other functions and tasks as assigned. Education/Experience/Skill Requirements: Bachelor's Degree in Human Services or nursing required. Master's degree in behavioral health/risk discipline, 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/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 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.