The Director of Quality and Performance Improvement is responsible for leading and overseeing all quality, safety, regulatory, and accreditation activities across the Behavioral Health Service Line. This role ensures compliance with CMS, Joint Commission, DNV, and state-specific behavioral health standards while driving continuous improvement initiatives across all behavioral health units housed within the acute care hospital. The Director of Quality may supervise Behavioral Health Quality Coordinator(s) and collaborate with clinical, administrative, and executive teams to promote a culture of safety and excellence. 

Data Collection, Management, and Interpretation

Lead the collection, validation, and management of QMSOC and QSOC data across all inpatient psychiatric facilities, outpatient behavioral health clinics, and Peer Recovery and Community Health Worker operations.

Ensure comprehensive and accurate data capture for all relevant service line functions, including clinical, operational, and quality-related metrics.

Collect, organize, and prepare behavioral health quality data for Advisory Board meetings and system-level reporting.

Collect, organize and submit required behavioral health data to Kentucky’s Department for Behavioral Health, Developmental and Intellectual Disabilities.

Design and maintain systems to collect and publish Quadruple Aim data (clinical quality, patients volumes, HR, and financial) across behavioral health settings.

Develop, update, and distribute facility-level and system-wide behavioral health scorecards that reflect key quality, safety, and operational metrics.

Input data, interpret trends, and utilize data visualization tools (Excel, Tableau, Power BI) to provide actionable insights to entity-specific leadership and multidisciplinary teams.

Quality Improvement

Collaborate with Behavioral Health Service Line Leadership to implement and monitor quality improvement plans aligned with organizational goals and regulatory standards.

Use collected data to drive targeted initiatives that improve behavioral health outcomes.

Facilitate multidisciplinary performance improvement teams focused on data-driven strategies.

Guide teams in interpreting data, setting measurable goals, and tracking progress toward improvement.

Review charts for patients in inpatient psychiatric units, outpatient behavioral health clinics, and those with primary or secondary behavioral health conditions in inpatient, emergency department, or ambulatory settings to identify potential quality of care opportunities outside the scope of inpatient psychiatry team data.

Accreditation and Regulatory Compliance

Serve as the primary liaison between the System Accreditation team and the Behavioral Health Service Line for regulatory data collection, interpretation, and presentation.

Maintain current knowledge of CMS, DNV, The Joint Commission, and other regulatory standards and guidance.

Lead compliance activities including interpretation and implementation of new regulatory requirements, proactive tracers, risk assessments, mock surveys, and corrective action plans.

Prepare data summaries and visualizations for regulatory reviews and mock surveys.

Provide guidance to facility teams on regulatory data definitions, collection methods, and reporting timelines to ensure consistency and accuracy.

Training & Development

Lead initiatives to educate staff and leaders on quality principles, service excellence, process improvement, and patient satisfaction best practices in behavioral health environments.

Develop training materials and conduct workshops to improve data literacy and promote a culture of data-driven improvement.

Stakeholder Engagement

Serve as a liaison between health system leadership, hospital teams, patients, and community partners to foster transparency and trust through clear communication of quality data and improvement opportunities.

Partner with clinical, administrative, and operational teams to integrate best practices informed by data analysis.

Work with Behavioral Health Service Line and local hospital leaders to analyze workplace violence incidents and find areas for improvement.

Education

Clinical licensure (RN, PharmD, RT, PT, LCSW etc.) required and

Bachelor’s degree in healthcare related field preferred or

Exceptionally qualified through experience in Quality / Performance Improvement settings.

Minimum Work Experience

Minimum 2 years in behavioral health setting

Minimum 1 year in quality/performance improvement or risk role in a hospital setting required

Minimum 1 year in hospital leadership role preferred

Expertise in national standards and compliance frameworks (TJC, DNV, CMS Quality Reporting etc.)

Licensures and Certifications

Licensure in a clinical field required

Certified Professional in Healthcare Quality – preferred

(required within 12 months of hire)

Lean six sigma – preferred

(required within 12 months of hire)

Required Skills, Knowledge, and Abilities

Demonstrated ability to self-organize and manage time to meet deadlines and manage competing priorities

Strong written and verbal communication skills, able to lead meetings, present findings, and facilitate interdisciplinary collaboration

Understanding of CMS Conditions of Participation and hospital regulatory standards

Proficient in use of organized performance improvement methodology (PDSA, lean, RCA etc.)

Experience training teams on quality tools, regulatory compliance updates, and performance improvement techniques

Knowledge of incident reporting system, risk mitigation strategies, and compliance protocols

Ability to input, analyze, and interpret clinical and operational data using tools such as Excel, Tableau, or Power BI, and to use these tools to build and maintain data visualization dashboards.

Experience with and insight into behavioral health clinical workflows, care transitions and service line performance across departments

Ability to align quality and performance goals with hospital-wide strategic initiatives

Skilled in leading cross-functional initiatives, managing timelines, and delivering measurable outcomes

Ability to guide teams through process redesign, culture shifts, and adoption of new standards

Skilled in drafting, reviewing, and implementing policies that support regulatory compliance and operational excellence

Inspire trust, model accountability, and foster a culture of continuous improvement