Director of Quality Improvement

Job Title: Director of Quality Improvement

Reports To : Chief Operating Officer (COO)

Location: Naples, FL

Company: David Lawrence Centers

Job Type: Salary/ Exempt

Hiring Incentives : Immediate PTO Accrual, Full Benefits W/401k Match, Professional Development & Tuition Assistance, EAP & Wellness Programs.

Position Summary

The Director of Quality Improvement provides strategic leadership for the organization's performance improvement, quality management, client safety, accreditation readiness, and outcomes measurement programs. This position is responsible for developing, implementing, and continuously improving a comprehensive quality framework that advances clinical excellence, regulatory compliance, operational effectiveness, and organizational performance.

The Director collaborates with executive leadership, clinical operations, medical staff, and support departments to establish a culture of quality, accountability, data-driven decision-making, and continuous improvement across all services.

For a behavioral health organization, this role serves as the primary leader for quality improvement initiatives, accreditation activities, quality reporting, performance measurement, risk reduction, and regulatory compliance efforts.

Essential Duties and Responsibilities:

Quality Management & Performance Improvement

• Establish and monitor organization-wide quality goals, key performance indicators (KPIs), and quality dashboards.
• Facilitate continuous quality improvement initiatives utilizing Lean, Six Sigma, PDSA, Root Cause Analysis, and other improvement methodologies.
• Identify opportunities to improve clinical outcomes, service delivery, access to care, client experience, and operational efficiency.
• Develop corrective action plans for identified performance gaps and monitor progress toward improvement goals.
• Coordinate quality committees and workgroups and ensure effective follow-through on action items.

Accreditation & Regulatory Compliance

• Serve as the organizational lead for accreditation, licensure, and certification readiness; and oversee all survey and monitoring preparation.
• Coordinate activities related to accreditation and licensure/certification standards (e.g., Joint Commission, Agency for Healthcare Administration (AHCA); Certified Community Behavioral Health Clinic (CCBHC) standards; Centers for Medicaid and Medicare Services (CMS); state licensing requirements, etc.).
• Monitor changes in healthcare regulations and quality requirements and communicate impacts to leadership.
• Conduct internal audits, tracers, and mock surveys to assess compliance and readiness.
• Develop and implement quality policies, procedures, and standards.

Data Analytics & Reporting

• Oversee collection, validation, analysis, and interpretation of quality and performance data.
• Develop executive-level quality dashboards and reports for leadership, committees, board members, and regulatory agencies.
• Monitor clinical quality measures, HEDIS measures, CCBHC quality measures, client safety indicators, and operational performance metrics.
• Utilize data analytics to identify trends, risks, opportunities, and emerging issues.
• Ensure timely submission of quality reports required by funding sources, accrediting bodies, and government agencies.

Client Safety & Risk Reduction

• Collaborate with Risk Management and Clinical Leadership to investigate adverse events, sentinel events, complaints, and safety concerns.
• Lead root cause analyses and performance improvement initiatives arising from quality or safety concerns.
• Promote a culture of client safety, transparency, and continuous learning.
• Monitor corrective actions and outcomes resulting from incident reviews.

Clinical Excellence

• Partner with clinical leaders to establish evidence-based practices and outcome measurement systems.
• Monitor clinical performance indicators and client outcomes.
• Support implementation of best practices and emerging standards of care.
• Promote measurement-based care and data-informed clinical decision-making.

Leadership & Team Development

• Provide supervision, coaching, and professional development for Quality division staff.
• Build collaborative relationships with leaders across clinical, operational, information technology, human resources, and finance departments.
• Serve as an internal consultant on quality improvement methodology and performance measurement.
• Foster a culture of accountability, innovation, and organizational learning.

Strategic Planning

• Support organizational strategic initiatives through quality and performance improvement strategies.
• Participate in organizational planning, goal setting, and performance management activities.
• Align quality initiatives with organizational mission, vision, values, strategic objectives, and regulatory requirements.
• Present quality performance and recommendations to executive leadership and governing boards.

Supervisory Responsibilities

May supervise:

• Quality Improvement and Risk Management Specialists
• Clinical Records Manager

Required Qualifications

Education

• Bachelor's degree in Healthcare Administration, Nursing, Public Health, Behavioral Health, Business Administration, or related field.

Experience

• Five (5) years of progressively responsible experience in healthcare quality improvement, quality management, accreditation, compliance, or performance improvement.
• Three (3) years of leadership or supervisory experience.
• Experience working within behavioral healthcare, hospital, community mental health, physician practice, or integrated healthcare settings.

Knowledge, Skills, and Abilities

• Strong knowledge of quality improvement methodologies and performance management principles.
• Knowledge of accreditation standards and regulatory requirements.
• Experience analyzing complex datasets and translating findings into actionable recommendations.
• Ability to lead cross-functional initiatives and manage multiple priorities.
• Excellent project management, facilitation, and organizational skills.
• Strong written, verbal, and presentation skills.
• Proficiency in Microsoft Office Suite, data visualization tools, and quality reporting systems.

Preferred Qualifications

• Master's degree in Healthcare Administration, Public Health, Nursing, Behavioral Health, Business Administration, or related field.
• Certified Professional in Healthcare Quality (CPHQ).
• Lean Six Sigma Green Belt, Black Belt, or equivalent performance improvement certification.
• Experience with CCBHC quality measures, HEDIS reporting, Joint Commission or CARF accreditation, CMS Conditions of Participation, behavioral health performance measurement, and population health and value-based care initiatives.

Key Performance Indicators

The Director of Quality Improvement may be evaluated on:

• Achievement of quality improvement goals.
• Accreditation and survey outcomes.
• Clinical outcome performance.
• Reduction in adverse events and compliance findings.
• Timeliness and accuracy of quality reporting.
• Performance measure improvement trends.
• Successful implementation of corrective action plans.
• Staff engagement and development outcomes.
• Board and leadership satisfaction with quality reporting and support.

Physical Requirements

• Prolonged periods of sitting and computer use.
• Ability to attend meetings throughout multiple facilities.
• Ability to travel locally as needed.
• Ability to occasionally lift up to 20 pounds.

Behavioral Health Organization-Specific Responsibilities

Lead CCBHC quality reporting, annual quality program evaluation, and quality governance structure.

• Oversee HEDIS, CMS Core Set, quality dashboard, and outcomes reporting activities.
• Coordinate quality support for crisis services, outpatient client services, substance use treatment, and care coordination programs.
• Manage quality initiatives related to Zero Suicide, client safety, access to care, client engagement, and clinical outcomes.
• Support preparation for future psychiatric hospital accreditation and CMS compliance activities.
• Partner with executive leadership on strategic quality initiatives that improve client outcomes and organizational performance.