ESSENTIAL FUNCTIONS:

• Develops and executes a comprehensive strategy for patient safety and quality outcomes aligned with the organization’s mission, regulatory requirements, and industry best practices.
• Develops, reviews, updates internal clinical procedures, outcomes measurement, patient satisfaction, clinical/financial tools, and resources.
• Works cross-functionally with clinical leaders, medical staff, risk management, compliance, and frontline teams to advance patient safety and quality initiatives.
• Collaborates with executive and operational leaders to embed quality improvement initiatives into daily operations, fostering a culture of safety and continuous improvement.
• Utilizes data analytics to drive decision-making and transparency.
• Works across technology and data teams to oversee the development, implementation, and tracking of key performance indicators (KPIs) to measure and enhance patient safety, clinical quality, and operational effectiveness.
• Establishes and refines systems for timely and effective reporting, investigation, and response to patient safety incidents, ensuring lessons learned are embedded in operations.
• Initiates and leads communications with regulatory agencies as appropriate.
• Ensures compliance with all federal, state, and accreditation standards related to patient safety and quality, including The Joint Commission, CARF, CMS, and state licensure requirements.
• Develops/maintains proficiency in regulatory requirements, including reporting and response to regulatory bodies.
• Leads the development and delivery of training programs to promote a culture of safety, high reliability, and accountability across all levels of staff.
• Builds and mentors a high-performing quality and patient safety team, providing leadership, guidance, and professional development opportunities.
• Oversees the performance of a matrixed team of quality and patient safety professionals to ensure implementation and ongoing monitoring of quality and compliance activities.
• Monitors industry trends and emerging best practices in patient safety and quality, adapting and implementing evidence-based strategies across the organization.
• Oversees implementation of policies, procedures, and practices as its related activities to maintain ethical and conduct standards.
• Ensures proper facility reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required.
• Leads investigations into alleged violations of rules, regulations, policies, and Codes of Conduct by evaluating and recommending investigations as appropriate. Coordinate resolution of ethics reports with the Chief Compliance Officer.

Leadership Functions:

• Identifies and prioritizes issues of importance, including those priority issues as set by leadership.  Collaborates with department leaders and corporate executive leaders, as needed.
• Communicates instructions, expectations and timelines clearly and concisely.
• Manages staff scheduling to maintain productivity levels, curtailing unnecessary overtime and/or excessive staff work hours.
• Maintains accountability expectations for self and staff in all areas of job performance. 
• Engages staff in quality and safety basics to ensure sustained, measurable compliance. 
• Identifies staff educational needs and ensures they are addressed with education programs that are attended by staff. 
• Holds staff accountable for non-compliance and safety concerns, as well as attendance, following policies, behavior, and adherence to the code of conduct. 

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

• Advanced degree(s) in healthcare-related fields, such as MD, PhD, MPH, MHA, MBA, PsyD, MSW, APRN, or related disciplines
• Ten or more years of experience in healthcare quality, patient safety, and/or clinical leadership, with at least five years in a senior leadership/management role.
• Experience within behavioral health, addiction treatment, or substance use disorder settings is highly preferred.
• Proven history of successfully implementing quality improvement initiatives in a multi-site and/or matrixed healthcare environment.
• Deep understanding of regulatory, accreditation standards, standard quality measures, and value-based care including The Joint Commission, CARF, CMS, NCQA, and state regulations.
• Proficiency in data analytics with experience utilizing data to drive strategic decision-making as well as to establish, track and trend performance towards quality and patient safety goals.
• Demonstrated ability to lead change management and foster a culture of continuous improvement, safety, and accountability.
• Experience with Lean Six Sigma, Model for Improvement, or other quality/performance improvement frameworks.
• Exceptional communication, facilitation, collaboration, and influencing skills with diverse stakeholders.
• Exercise sound judgment in responding to inquiries; understands when to escalate inquiries to the next level.
• Self-motivated with strong organizational skills and superior attention to detail.
• Must be able to manage multiple tasks/projects simultaneously within inflexible time frames. Ability to adapt to frequent priority changes.
• Capable of working within established policies, procedures and practices prescribed by the organization.
• Willingness and ability to travel extensively across the organization’s multi-state footprint.

LICENSES/DESIGNATIONS/CERTIFICATIONS:

• Certified Professional in Healthcare Quality (CPHQ) or equivalent certification.
• Experience with Lean Six Sigma or other quality improvement frameworks.
• Familiarity with telemedicine and digital health applications in SUD care.

WORK LOCATION:

This position is onsite and is not a remote position.

SUPERVISORY REQUIREMENTS:

Ten or more years’ supervisory/management experience required, preferably in behavioral health.