Sonora Behavioral Health Hospital is seeking an experienced and driven Director of Quality and Accreditation to join our leadership team. Sonora is a leading behavioral health facility dedicated to providing high-quality, compassionate care to children, adolescents, adults, and families facing mental health and substance use challenges. Our mission is grounded in patient safety, clinical excellence, and continuous improvement, supported by evidence-based practices and a multidisciplinary treatment approach.

The Director of Quality and Accreditation plays a critical leadership role in advancing patient safety, regulatory readiness, and clinical program excellence across the facility. This position is responsible for overseeing all aspects of quality assurance, performance improvement (QAPI), accreditation, and regulatory compliance at the local, state, and federal levels. The Director serves as a subject matter expert, strategic partner, and visible leader, collaborating closely with executive leadership, medical staff, and corporate partners to ensure survey readiness, treatment program fidelity, and sustained compliance with Joint Commission, CMS, and other regulatory standards.

This role is ideal for a quality-focused healthcare leader with a strong background in behavioral health, accreditation, and performance improvement who is passionate about driving a culture of safety, accountability, and zero harm.

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 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.
  • Utilize collected data regarding the outcome of activities for delivering continuously improving services.
  • Conduct annual preparation and evaluation of the facility QAPI Program.
  • Complete process improvement projects and incorporate the 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 (ex. national quality measures such as HBIPS).
  • Identify key aspects of care relevant indicators and evaluation of data using formal and informal feedback from consumers of services and other collateral sources is aggregated and used 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 achievement of zero- or standard-level survey outcomes.
  • Facility-wide support – collaborate with other departments to sustainably implement best-practices in regulatory/accreditation compliance as 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 for all relevant regulatory and accrediting bodies at the local, state, and federal level.
  • Develop and maintain proficiency in the functionality and auditing within electronic platforms such as electronic patient observations and the electronic medical record, as applicable.
  • Lead Root-Cause Analyses and conduct timely and regular evaluation of serious incidents, complaints, grievances and related investigations to:
    • Identification of events, trends and patterns that may affect client health, safety and or treatment efficacy,
    • Committee evaluation findings and recommendations submitted to agency management for corrective action,
    • Implemented actions, outcomes, trends analyzed over time
  • Develop corrective action plans for the resolution of areas of regulatory vulnerability or those which could compromise patient safety in collaboration with other facility leaders.
  • Ensure proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required.
  • Ensure proper reporting of incidents and adverse clinical outcomes to duly authorized enforcement agencies or regulatory agencies as appropriate and/or required.
  • In conjunction with assigned corporate Division Quality Director, initiate and lead communications with regulatory agencies as appropriate.
  • Develop sustainable performance improvement practices through analysis of data and prioritization of efforts to improve survey readiness and consistency of care delivery using expected best-practices.
  • Ensure multidisciplinary ownership of best-practices in self-monitoring, auditing, and process improvement, escalating opportunities for improved engagement to the facility CEO as appropriate.
  • Ensures strategic and operational implementation of regulatory requirements, guidelines, and standards of federal, state, and local licensing agencies, accrediting and certifying organizations.
  • Collaborates with Division and Corporate entities and external parties to ensure strategic quality and patient safety initiatives are fully executed at the facility level. Facilitates effective communication with facility and division leadership regarding key clinical performance improvement activities and initiatives.
  • Serves as a technical advisor, educator and internal consultant to all hospital management, staff, and physicians on the use of performance improvement tools and techniques, analytical techniques, and statistical applications.
  • Ensure facility compliance with policies and applicable standards as required by regulatory/accrediting bodies.
  • 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/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.

• Leadership – serve as a visible, engaged, and dynamic member of the facility leadership team.
  • Chairs 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.
  • Oversees the Culture of Safety Survey and follow-up action planning and sustainment processes.
  • Identification of problems or potential problems to prevent risks to patients and staff. Proposes corrective steps that may include, but are not limited to:
    • Changes in policies/procedures,
    • Staffing and assignment changes,
    • Additional education or training for staff,
    • Addition or deletion of services

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:

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​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. 

AHMKT

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