Director of QI/RM/PI (Quality Improvement/Risk Management/Performance Improv.)

POSITION TITLE: Director, QI/RM/PI (Quality Improvement/Risk Management/Performance Improvement)

REPORTS TO: Chief Executive Officer (CEO)/Chief Clinical Officer

PAY RANGE: $140-170k/year, Exempt

At Sacramento Behavioral Healthcare Hospital, we're on a mission to deliver compassionate, high-quality behavioral health care and we need a sharp, driven leader to help us make sure we're doing it right, every single day. That's where you come in.

As our Director of Quality Improvement, Risk Management & Performance Improvement, you'll sit at the intersection of data, compliance, and real human impact — turning insights into action and helping us build something we're all proud of.

KEY RESPONSIBILITIES:

Quality Improvement & Performance Improvement (QI/PI)

• Lead the design, implementation, and evaluation of the hospital's integrated Quality and Performance Improvement Program, ensuring alignment with CMS Conditions of Participation, The Joint Commission (TJC) Behavioral Health Care standards, and DHCS requirements
• Facilitate interdisciplinary QI/PI committees, workgroups, and data‑driven initiatives to improve clinical outcomes, patient experience, and operational efficiency
• Oversee data collection, analysis, and reporting for key quality metrics, including adverse events, readmissions, seclusion/restraint use, and patient satisfaction
• Partner with clinical and operational leaders to develop corrective action plans and monitor sustained improvement
• Promote a culture of continuous learning, transparency, and accountability across the organization
  
  

Risk Management (RM)

• Direct the hospital's Risk Management Program, including incident reporting, investigations, root cause analyses (RCA), and proactive risk assessments (FMEA)
• Serve as the primary point of contact for patient safety events, grievances, and regulatory reporting (CDPH, DHCS, CMS)
• Maintain the hospital's risk register and lead strategies to reduce clinical, operational, and environmental risks
• Collaborate with legal counsel and insurance carriers on claims management and risk mitigation strategies
• Provide training and coaching to staff on risk prevention, documentation standards, and safety practices
  
  

Accreditation & Regulatory Compliance

• Ensure continuous readiness for all accreditation and licensing surveys, including TJC, CMS, DHCS, and county mental health plans
• Conduct mock surveys, tracers, and compliance audits to identify gaps and drive corrective actions
• Maintain current knowledge of federal and California behavioral health regulations, ensuring timely updates to policies and procedures
• Coordinate submission of required regulatory reports and documentation
• Serve as the hospital's Accreditation Manager and primary liaison with external regulatory bodies
  
  

Leadership & Collaboration

• Lead and mentor a multidisciplinary team responsible for QI, RM, PI, and compliance functions
• Collaborate with nursing, medical staff, clinical services, and administrative departments to integrate quality and safety into daily operations
• Present performance dashboards, risk trends, and compliance updates to executive leadership and the Board of Directors
• Champion a patient‑centered, trauma‑informed, recovery‑oriented approach across all initiatives
  
  

Requirements

Required Knowledge and Experience:

• Bachelor's degree in Nursing, Healthcare Administration, Public Health, Behavioral Health, or related field
• Minimum of two (2) years of experience in quality improvement, risk management, or regulatory compliance in a healthcare setting
• Experience in behavioral health or psychiatric inpatient services
• Strong knowledge of CMS, TJC Behavioral Health Care standards, DHCS, and California hospital standards and regulations
• Demonstrated experience leading PI projects and conducting RCA/FMEA
• Excellent analytical, communication, and leadership skills
• Current knowledge of continuous quality improvement methodology
• Current CPR certification or obtained during initial orientation period.
• Current HWC (Handle with Care) or obtained during initial orientation period
  
  

Preferred Knowledge and Experience:

• Master's degree in a related field
• Certified Professional in Healthcare Quality (CPHQ), Certified Professional in Healthcare Risk Management (CPHRM), or equivalent
• Experience with trauma-informed care frameworks and high-reliability principles
• Prior leadership experience in a hospital or behavioral health organization
  
  

Skills and Abilities:

• Maintains strict patient confidentiality
• Demonstrates sensitivity and respect for individuals from diverse social, cultural, economic, and educational backgrounds
• Strong interpersonal, written, and verbal communication skills
• Able to collaborate effectively with staff at all levels and work both independently and as part of a team
• Skilled in data collection, analysis, interpretation, and performance analytics
• Strong organizational skills with the ability to manage multiple priorities, meet deadlines, and operate in a fast‑paced environment
• Exercises good judgment, problem‑solving ability, and systems‑level strategic thinking
• Proficient in Microsoft Office applications, including Outlook, Word, Excel, and PowerPoint
• Demonstrated ability to lead, influence, and motivate others while fostering collaborative teamwork
• Commitment to patient safety, equity, quality care, and understanding of behavioral health clinical environments
  
  

Physical Requirements:

While performing the duties of this job, this position is frequently required to do the following:

• Use standard office equipment and access, input, and retrieve information from a computer. Use computer keyboard with manual and finger dexterity and wrist-finger speed sufficient to perform repetitive actions efficiently for extended periods of time.
• Communicate effectively in person or via telephone in a manner which can be understood by those with whom the person is speaking, including a diverse population.
• Give and follow verbal and written instructions with attention to detail and accuracy.
• Perform complex mental functions and basic arithmetic functions; interpret complex laws, regulations, and policies; collect, interpret, and/or analyze complex data and information
• Vision: see details of objects at close range
• Coordinate multiple tasks simultaneously.
• Reach forward, up, down, and to the side.
• Sit or stand for minimum periods of one hour at a time and come and go from the work area repeatedly throughout the day
• Lift up to five (5) pounds
  
  

Benefits

• Medical
• Vision
• Dental
• 401(k)
• 200 PTO hrs/year
• $25,000 Life insurance policy is provided at no charge to the employee