Director Quality & Performance Improvement Behavioral Health

Appalachian Regional Healthcare (ARH); Hazard (KY); On-site; USD 120,000 - 170,000; Full time

Job summary

Appalachian Regional Healthcare (ARH) seeks a Director of Quality and Performance Improvement to lead cross-functional teams across behavioral health services, ensuring CMS, Joint Commission, and DNV standards are met while driving continuous improvement. You will oversee data collection, reporting, and scorecards for system-wide quality metrics.

The role requires clinical licensure, hospital leadership experience, and a track record in quality/performance improvement with proficiency in Excel,

Qualifications

• Clinical licensure (RN, PharmD, RT, PT, LCSW etc.) required.
• Bachelor’s degree in healthcare related field preferred.
• Experience in Quality/Performance Improvement settings.
• Minimum 2 years in behavioral health setting.
• Minimum 1 year in quality/performance improvement or risk role in a hospital setting.
• Leadership experience in hospital setting preferred.
• CPHQ certification preferred (required within 12 months).
• Lean Six Sigma preferred (required within 12 months).

Responsibilities

• Lead data collection, validation, and management across behavioral health services.
• Develop facility and system-wide quality scorecards.
• Ensure compliance with CMS, Joint Commission, DNV, and state standards.
• Guide teams using data-driven improvement and PDSA/Lean methods.
• Collaborate with leadership to promote safety and continuous improvement.
• Prepare data summaries for regulatory reviews and mock surveys.
• Mentor Behavioral Health Quality Coordinators.

Skills

Leadership

Data analysis

Regulatory compliance

Cross-functional collaboration

Communication

Project management

Quality tools

Change management

Education

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

Bachelor’s degree in healthcare related field

CPHQ certification

Lean Six Sigma certification

Tools

Excel

Tableau

Power BI

Job description

Overview

The Director of Quality and Performance Improvement is responsible for leading and overseeing all quality, safety , regulatory, and accreditation activities across the B ehavioral H ealth S ervice L ine. 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.

Overview

The Director of Quality and Performance Improvement is responsible for leading and overseeing all quality, safety , regulatory, and accreditation activities across the B ehavioral H ealth S ervice L ine. 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.

Responsibilities

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.

Qualifications

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