Quality Assurance and Compliance Director

Description

The Quality Assurance and Compliance Director is responsible for developing, implementing, and maintaining the hospital’s Quality Assessment and Performance Improvement (QAPI) and Compliance Programs. This position ensures the hospital meets and exceeds standards established by regulatory and accreditation agencies, including The Joint Commission (TJC), the Massachusetts Department of Mental Health (DMH), the Bureau of Substance Addiction Services (BSAS), and the Centers for Medicare & Medicaid Services (CMS).

This role works collaboratively with the Chief Nursing Officer, Director of Facility Operations, CEO, and other department leaders to coordinate data-driven quality assurance activities, regulatory compliance functions, and survey preparedness. The position promotes continuous regulatory readiness, supports the hospital’s Quality Improvement (QI) Plan, manages incident reporting and patient safety initiatives, and provides education and consultation to staff and leadership regarding compliance and risk standards.

The Director provides leadership, coordination, and oversight of all quality and compliance activities, supporting the organization’s mission to provide safe, effective, and patient-centered behavioral healthcare.

Essential Duties and Responsibilities

• Program Development & Oversight
  • Develop, implement, and manage the hospital’s QAPI and Compliance Programs in alignment with regulatory and accreditation standards.
  • Ensure the integration of quality and compliance activities into all levels of the organization.
  • Ensure risk management, patient safety, and compliance data are integrated into QI reporting.
  • Maintain documentation for accreditation readiness (Joint Commission, CMS, BSAS, DMH), including Measures of Success, FMEAs, and audit tools.
  • Coordinate and lead Quality and Compliance Committees, and co-lead Patient Safety Committee. May co-lead other committees as assigned.

• Regulatory & Accreditation Compliance
  • Ensure ongoing readiness for TJC, DMH, BSAS, and CMS surveys and inspections.
  • Serve as primary liaison during all regulatory surveys, audits, and inspections.
  • Monitor changes in laws, regulations, and standards, and update hospital policies and practices accordingly.
• Performance Measurement & Reporting
  • Collect, analyze, and report data related to clinical outcomes, patient safety, and performance indicators.
  • Conduct root cause analyses, identify trends, and facilitate corrective action planning.
  • Provide regular quality and compliance reports to hospital leadership and the Governing Body.
• Education & Training
  • Develop and deliver staff education on quality improvement, patient safety, and compliance standards.
  • Support department leaders in understanding and applying regulatory and accreditation requirements.
• Risk Management & Incident Oversight
  • Oversee the hospital’s incident reporting, investigation, and follow-up processes.
  • Ensure timely reporting to regulatory agencies when required.
  • Collaborate with leadership on risk reduction strategies.
• Policy Development & Review
  • Maintain and review hospital policies and procedures for regulatory alignment.
  • Ensure timely policy updates and staff notification.

Communication

• Demonstrates professionalism, clarity, and respect in all forms of communication.
• Communicate effectively with staff, leadership, patients, and regulatory agencies.
• Maintains open, collaborative communication across departments to support transparency and teamwork.
• Demonstrates appropriate communication and composure in challenging or high-pressure situations, including when addressing compliance findings, staff concerns, or regulatory interactions.
• Provides constructive feedback and education to staff in a supportive and solution-focused manner.
• Ensures communication of quality and compliance data is accurate, timely, and easily understood by diverse audiences.

Key Performance Indicators (KPIs)

• 100% of required regulatory reports submitted within mandated timelines.
• 100% of policies reviewed and updated per scheduled cycle.
• No Condition-level findings during regulatory surveys.
• 90% of incident reports investigated and closed within set timeframe.
• Evidence of ongoing performance improvement initiatives documented in QAPI reports.

Compliance Responsibility

• Adheres to all hospital policies and procedures.
• Ensures compliance with all applicable standards, including TJC, DMH, BSAS, and CMS.
• Maintains confidentiality in accordance with HIPAA and hospital standards.
• Reports any suspected violations of compliance or safety standards immediately.
• May act as Privacy Officer and assist in HRO complaint resolutions.

Competencies

• Knowledge of behavioral health care delivery systems.
• Commitment to ethical practice and patient rights.
• Ability to work collaboratively across interdisciplinary teams.
• Strong problem-solving, decision-making, and leadership skills.
• Capacity to manage confidential information with discretion.

Qualifications

• Licensure: Current Massachusetts licensure as a Registered Nurse (RN), Licensed Practical Nurse (LPN), or Licensed Independent Clinical Social Worker (LICSW) required.
• Education: Bachelor’s degree in Nursing, Social Work, Health Care Administration, or related field required; Master’s degree preferred.
• Experience:
  • Minimum of three (3) years of progressive experience in quality management, regulatory compliance, or performance improvement in a healthcare setting.
  • Experience in psychiatric or behavioral health strongly preferred.
• Knowledge/Skills:
  • Comprehensive knowledge of The Joint Commission (TJC), Massachusetts Department of Mental Health (DMH), Bureau of Substance Addiction Services (BSAS), and Centers for Medicare & Medicaid Services (CMS) standards and reporting requirements.
  • Strong analytical, organizational, and project management skills.
  • Ability to interpret regulations and accreditation standards and translate them into practice.
  •  
  • Excellent written, verbal, and interpersonal communication skills.
  • Proficiency in Microsoft Office Suite and data reporting systems.

Salary : $115,000 - $125,000