Director of Quality

Corporate Director of Quality

Inpatient Psychiatric Hospitals

Aligned with CMS Conditions of Participation & The Joint Commission

Position Summary

The Corporate Director of Quality provides system-level leadership, direction, and oversight of the Quality Assessment and Performance Improvement (QAPI) program for inpatient psychiatric hospitals. This role ensures sustained compliance with CMS Psychiatric Hospital Conditions of Participation (CoPs) and The Joint Commission accreditation standards, while advancing a culture of patient safety, continuous improvement, and data-driven clinical excellence across all facilities.

The Corporate Director of Quality partners with executive leadership, clinical leaders, and compliance to integrate regulatory requirements into daily operations and organizational strategy.

Essential Responsibilities

1. CMS Conditions of Participation – QAPI Oversight

• Lead and maintain an effective QAPI program that meets CMS Psychiatric Hospital CoP requirements.
• Ensure quality activities are:
  • Data-driven
  • Ongoing
  • Hospital-wide
  • Integrated across disciplines
• Monitor and analyze quality indicators related to:
  • Patient safety
  • Clinical outcomes
  • Restraint and seclusion
  • Patient rights
  • Medication safety
• Ensure corrective actions are implemented, monitored, and sustained.

1. Joint Commission Accreditation & Continuous Readiness

• Oversee continuous readiness for The Joint Commission accreditation.
• Ensure compliance with applicable TJC standards including:
  • Leadership (LD)
  • Provision of Care (PC)
  • Performance Improvement (PI)
  • Environment of Care (EC)
  • Human Resources (HR)
  • Information Management (IM)
• Lead tracer methodology, mock surveys, and gap analyses.
• Coordinate response to RFIs and Evidence of Standards Compliance (ESC).

1. Patient Safety & Risk Reduction

• Lead patient safety initiatives focused on inpatient psychiatric risk, including:
  • Suicide prevention
  • Elopement risk
  • Restraint and seclusion reduction
  • Violence and assault prevention
• Collaborate with Risk Management and Compliance on:
  • Root Cause Analyses (RCAs)
  • Event investigations
  • Sentinel events
• Track trends and ensure implementation of corrective and preventive actions.

1. Quality Data, Analytics & Reporting

• Develop and maintain quality dashboards aligned with CMS and TJC expectations.
• Analyze quality data to identify trends, risks, and improvement opportunities.
• Present quality performance reports to:
  • Executive leadership
  • Governing boards
  • Quality and Compliance Committees
• Ensure transparency, accuracy, and meaningful interpretation of data.

1. Performance Improvement Leadership

• Lead and support Performance Improvement Projects (PIPs) required by CMS.
• Ensure PI methodology (PDSA, Lean, Six Sigma, or equivalent) is consistently applied.
• Coach leaders and frontline teams in performance improvement techniques.
• Validate effectiveness and sustainability of improvement efforts.

1. Policy, Process & Documentation Alignment

• Partner with Compliance and Clinical Leadership to ensure:
  • Policies align with CMS CoPs and Joint Commission standards
  • Clinical processes support regulatory compliance
• Ensure documentation practices support quality outcomes and regulatory expectations.
• Participate in policy review and approval processes.

1. Education & Quality Culture

• Provide ongoing education to leadership and staff on:
  • Quality standards
  • CMS and Joint Commission expectations
  • Patient safety principles
• Promote a culture of safety, accountability, and continuous improvement.
• Support leadership development related to quality and regulatory readiness.

1. Corporate & Facility Collaboration

• Provide system-level oversight and support to facility quality leaders.
• Standardize quality metrics, reporting, and improvement processes across hospitals.
• Serve as a subject-matter expert for quality during surveys, audits, and investigations.
• Collaborate with:
  • Compliance
  • Risk Management
  • Nursing and Medical Leadership
  • Operations

Core Competencies

• Expert knowledge of CMS Psychiatric Hospital Conditions of Participation.
• In-depth understanding of Joint Commission inpatient psychiatric standards.
• Strong performance improvement and data analytics skills.
• Proven leadership in patient safety and quality programs.
• Excellent communication and executive presentation abilities.

Required Qualifications

• Bachelor’s degree in Nursing, Healthcare Administration, Quality, or related field (Master’s preferred).
• Minimum 5–7 years of healthcare quality leadership experience.
• Experience in inpatient psychiatric or behavioral health settings strongly preferred.
• Demonstrated success with CMS surveys and Joint Commission accreditation.

Preferred Qualifications

• RN license preferred.
• Certification such as CPHQ (Certified Professional in Healthcare Quality) strongly preferred.
• Experience in multi-facility or corporate healthcare systems.