Director of Quality and Accreditation

Overview

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. The Director leads and oversees all aspects of policy development; comprehensive implementation of Acadia’s clinical protocols, operational quality oversight standards, and programmatic expectations; critical incident reporting; regulatory engagement; certification achievement and maintenance; and oversight of the QAPI program and ongoing regulatory readiness strategies at the facility. Through routine presence in patient care areas, data analysis, documentation monitoring, and sharing of subject‑matter expertise, the Director ensures a proactive, multidisciplinary focus on quality and excellence within the facility.

Coastal Pines will be a modern, purpose‑built facility and a cornerstone of behavioral health care in Northeast Florida, designed to meet the growing demand for high‑quality psychiatric services in the region. The 144‑bed behavioral health hospital, located in St. Johns, will offer a full continuum of services including inpatient psychiatric care, Partial Hospitalization Program (PHP), Intensive Outpatient Program (IOP), and Electroconvulsive Therapy (ECT).

What We Offer

• Competitive compensation package including performance‑based incentives
• Comprehensive medical, dental, and vision insurance
• 401(k) plan with company match through Acadia Healthcare
• Equity/stock‑based incentive awards for long‑term financial growth
• Generous paid time off including vacation, holidays, and sick days

If you're ready to lead with purpose and drive lasting impact in the behavioral health space, we invite you to consider joining us at Coastal Pines Behavioral Health.

Responsibilities

• 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 vendor database entry for Inpatient Psychiatric Core Measures (e.g., national quality measures such as HBIPS).
  • Identify key care indicators and evaluate data using formal and informal feedback from consumers and other collateral sources, aggregating and using them 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.
  • Collaborate with other departments to sustainably implement best‑practices in regulatory/accreditation compliance, 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 evaluations of serious incidents, complaints, grievances and related investigations to identify events, trends and patterns that may affect client health, safety, and treatment efficacy.
  • Submit corrective action plans for the resolution of areas of regulatory vulnerability or those that could compromise patient safety, in collaboration with other facility leaders.
• Leadership – serve as a visible, engaged, and dynamic member of the facility leadership team.
  • Chair 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 hiring, development, training, performance management, and communication to ensure effective and efficient operations.
  • Oversee the Culture of Safety Survey and follow‑up action planning and sustainment processes.
  • Identify problems or potential problems to prevent risks to patients and staff, proposing corrective steps such as policy changes, staffing changes, additional education or training, and additions or deletions of services.
• Other Functions – Perform other functions and tasks as assigned.

Qualifications

• 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.

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.

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.

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