Director of Quality and Accreditation

Montrose Behavioral Health Hospital is seeking a dynamic and experienced Director of Quality and Accreditation to lead our facility’s efforts in ensuring the highest standards of patient care and safety. This leadership role is responsible for overseeing regulatory compliance, quality assurance programs, and continuous improvement initiatives across all clinical and operational areas. The Director will guide the development and implementation of quality protocols, manage accreditation processes, and lead the Quality Assurance and Process Improvement (QAPI) program.

The ideal candidate will be a proactive, strategic thinker with a strong commitment to achieving excellence in care delivery and regulatory readiness.

At Montrose Behavioral Health Hospital for Adults, located in Chicago not far from Lake Michigan, we provide premier inpatient care for children ages 5-12, adolescents ages 13-17, adults age 18 and older, and senior adults age 55 and older. We also offer outpatient care for adolescents and adults. With a dedicated team of professionals, the hospital offers a supportive environment designed to promote healing and long‑term stability.

Working at Montrose Behavioral Health Hospital offers a meaningful opportunity to support patients on their path to healing while being part of a compassionate, multidisciplinary team. It’s a rewarding environment where colleagues are dedicated to providing throughtful and patient centered care every day.

Montrose Behavioral Health Hospital offers an extensive array of benefits to our valued team members. Current offerings encompass:

• Medical, Dental, and Vision Insurance coverage
• Health Savings Account (HSA) and Flexible Spending Account (FSA) options
• Company-paid Basic Life & AD&D insurance
• Disability benefits
• 401(k) Retirement Plan with a company match
• Employee Assistance Program (EAP) and Employee Discount Program
• Paid Holidays for work‑life balance
• Paid Time Off (PTO)
• Tuition Reimbursement opportunities for career advancement

PURPOSE STATEMENT:

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. As such, the Director is responsible for leading and overseeing all aspects of policy development; comprehensive implementation of Acadia’s prescribed clinical protocols, operational quality oversight standards, and programmatic expectations;

critical incident reporting; regulatory engagement, including development and submission of plans of correction; certification achievement and maintenance; oversight of the quality assurance and process improvement (QAPI) program; and on‑going regulatory readiness strategies at the facility. Through routine physical presence in patient care areas, data analysis and documentation monitoring, and intentional sharing of deep subject‑matter expertise, the Director will ensure a proactive, multidisciplinary focus on quality and excellence within the facility.

Salary Range: $95,401-$110,242

ESSENTIAL FUNCTIONS:

• 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.
    • Coordin…