Director Quality & Performance Improvement Behavioral Health

Overview

The Director of Quality and Performance Improvementis responsible for leading and overseeing all quality,safety, regulatory, and accreditation activities acrossthe

Behavioral Health Service Line .This role ensures compliance with CMS, Joint Commission,DNV, and state-specific behavioral health standards while driving continuous improvement initiatives acrossallbehavioral health units housed withintheacute care hospital. The Director of Qualitymaysupervise 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,…