Quality Director

Quality Director

HUMAN RESOURCES Full Time Amityville, NY, US

Quality Director

Brunswick Hospital Center (Inpatient Behavioral Healthcare)

Position Summary

The Quality Director provides strategic leadership for Brunswick Hospital Center’s quality management and performance improvement program. This role is responsible for analyzing trends, identifying systems issues, and driving organization-wide improvement using data provided by the Incident Management / Clinical Risk team.

The position maintains a clear separation of duties so that special investigations and Justice Center case management remain the responsibility of the Incident Management team. The Quality Director ensures alignment with OMH, Joint Commission, CMS, and Justice Center expectations at the systems level.

Essential Duties and Responsibilities

Quality and Performance Improvement

• Develop and lead the hospital’s annual Quality and Performance Improvement Plan.
• Design and oversee systems for collecting, analyzing, and reporting quality and incident trend data.
• Chair the Performance Improvement Committee and ensure follow-through on improvement projects.
• Partner with department leaders to establish measurable quality goals and monitor progress.
• Track the implementation and effectiveness of Corrective Action Plans (CAPs) across the organization.
• Support organizational review of sentinel events and high-risk events through systems analysis and monitoring of resulting improvements.

Collaboration with Incident Management

• Receive completed investigation findings and case-specific data from the Clinical Risk / Incident Management team.
• Use this information for systems-level analysis and improvement without conducting or duplicating investigations.
• Ensure special investigations and Justice Center case management remain the responsibility of the Incident Management team.

Compliance and Reporting

• Prepare and submit required quality and performance improvement reports to internal leadership, the Board, and external agencies (OMH, CMS, Joint Commission) as applicable.
• Ensure timely and accurate reporting of quality indicators, trend data, and improvement outcomes.
• Monitor compliance with regulatory reporting timelines and documentation standards related to quality and performance improvement.
• Maintain documentation demonstrating the effectiveness of the quality program for surveys and audits.
• Coordinate the hospital’s response to quality-related findings from external reviews, ensuring corrective actions are tracked to completion.

Survey Readiness and Regulatory Compliance

• Coordinate survey readiness activities and maintain ongoing compliance with Joint Commission, CMS, OMH, and related standards.
• Serve as a liaison with OMH on quality and performance improvement matters (distinct from day-to-day incident reporting and Justice Center investigations).
• Oversee systems-level tracking and trending of patient complaints and grievances.

Leadership and Communication

• Facilitate communication of quality data and improvement initiatives to medical staff, leadership, and the Board.
• Identify and recommend resources, training, and process changes needed to sustain a culture of safety and continuous improvement.

Qualifications

• Bachelor’s degree in nursing or a related field required; Master’s degree preferred.
• Current RN or NP licensure in New York preferred; other advanced clinical or quality credentials (e.g., CPHQ) considered.
• Minimum of 5 years of progressive quality, performance improvement, or risk management experience in a behavioral health or hospital setting.
• Demonstrated experience with Joint Commission or CMS survey readiness.
• Strong data analysis, presentation, and facilitation skills.
• Experience working with OMH or Justice Center expectations at a systems/compliance level preferred.
• Prior supervisory or leadership experience preferred.

*Benefits offered. Salary commensurate with experience.