About the Job:
PURPOSE STATEMENT:The Chief Quality & Patient Safety Officer provides executive leadership and is accountable for developing and implementing patient safety, clinical quality, and performance improvement strategies across all service lines. This role shapes the organization’s vision for high-reliability care, driving enterprise-wide initiatives that improve patient outcomes, reduce risk, and foster a culture of quality and patient safety. Operating within a matrixed environment, the Chief Quality & Patient Safety Officer collaborates with executive and operational leadership to ensure the seamless integration of quality and patient safety priorities into daily clinical and operational practices. The Chief Quality & Patient Safety Officer oversees the Vice President of Quality and Patient Safety and partners closely with clinical, regulatory, compliance, and operational teams to drive sustainable improvements and ensure organizational excellence.
Roles and Responsibilities:
ESSENTIAL FUNCTIONS:
- Enterprise Quality and Patient Safety Strategy
- Develops and leads the enterprise Quality and Patient Safety strategy across acute psychiatric and substance use disorder service lines, ensuring alignment with organizational priorities, clinical standards, regulatory requirements, and evidence-based practices.
- Evaluates the maturity and effectiveness of existing Quality and Patient Safety programs and builds, enhances, or standardizes systems and processes needed to support a scalable multistate organization.
- Translates quality and patient safety data, emerging risks, operational trends, and regulatory developments into actionable enterprise strategies designed to improve patient outcomes and reduce preventable harm.
- Establishes enterprise priorities and annual Quality and Patient Safety goals in partnership with the Chief Medical Officer, executive leadership, operational leadership, and clinical leaders.
- Ensures Quality and Patient Safety strategies are effectively translated from the Services and Support Center into sustainable practices at the facility level.
- Quality Analytics, Reporting and Performance Intelligence
- Leads the development of an enterprise quality analytics strategy that transforms clinical, patient safety, regulatory, and operational data into actionable information for leaders across the organization.
- Evaluates trends across states, facilities, service lines, and patient populations to identify systemic risks, emerging patterns, performance variation, and opportunities for improvement.
- Partners closely with Information Technology and other data and analytics resources to improve data integrity, reporting capabilities, dashboards, visualization, and access to timely quality information.
- Establishes and maintains an executive Quality and Patient Safety scorecard that focuses leadership attention on the organization's most meaningful indicators of clinical quality, patient safety, regulatory performance, and improvement.
- Uses data and comparative analysis to distinguish isolated facility events from broader organizational trends requiring enterprise intervention.
- Patient Safety, Event Management and Performance Improvement
- Provides executive oversight of the organization's patient safety program and establishes systems for identifying, evaluating, escalating, and responding to significant clinical and safety events.
- Leads or facilitates enterprise discussions regarding adverse events, recurring events, near misses, and emerging safety concerns, including the use of recurring event review forums to identify common themes and organizational risks.
- Ensures significant events and trends result in appropriate root cause analysis, corrective action, performance improvement initiatives, and dissemination of lessons learned across applicable facilities.
- Develops strategies designed to reduce the frequency and severity of preventable incidents and monitors whether interventions produce measurable and sustained improvement.
- Promotes high reliability, continuous improvement, accountability, and proactive risk identification throughout the organization.
- Interdisciplinary Leadership and Operational Partnership
- Partners with Nursing, Medical, Clinical, Operations, Compliance, Risk Management, Information Technology, Human Resources, and other functions to identify quality concerns and implement sustainable improvement strategies.
- Serves as an executive advisor to facility and operational leadership regarding quality performance, patient safety risks, significant trends, and opportunities for improvement.
- Leads constructive performance discussions with facilities and operational teams, balancing accountability with collaboration, problem solving, and support for sustainable improvement.
- Builds organizational alignment around Quality and Patient Safety priorities by communicating complex clinical and analytical information in a manner that is clear, credible, actionable, and appropriate for the board of directors, executive, operational, and clinical audiences.
- Develops strong partnerships with operational leaders and clinical teams while maintaining the independence and professional judgment necessary to appropriately escalate quality and patient safety concerns.
- Regulatory, Accreditation and Quality Program Leadership
- Provides executive leadership to the Quality and Patient Safety function, while working in an integrated Nursing, Clinical, Quality, Accreditation and Regulatory team all reporting to the Chief Medical Officer. The Chief of Quality and Patient Safety and the Chief of Nursing and Clinical meet regularly and work together with the Chief Medical Officer to plan, develop, and implement a system-wide integrated approach to providing high level clinical care in a challenging environment of behavioral health and addiction services.
- Establishes clear responsibilities, performance expectations, operating rhythms, and accountability across the enterprise for Quality and Patient Safety functions.
- Working collaboratively with the Chief of Nursing and Clinical Services, as well as the SVP of Regulatory and Accreditation, ensures organizational readiness and sustained compliance with applicable federal, state, accreditation, and licensure requirements, including requirements established by CMS, The Joint Commission, CARF, and state regulatory agencies.
- Develops and mentors a high performing team capable of supporting a geographically dispersed, multistate portfolio while maintaining appropriate enterprise standards and facility level accountability.
- Monitors evolving industry practices and quality methodologies and determines when changes to organizational practices, policies, measurement systems, or improvement priorities are warranted.
ADDITIONAL RESPONSIBILITIES:
- Complies with organizational policies, procedures, performance improvement initiatives and maintains regulatory and industry standards.
- Maintains regular and reliable attendance.
- Exempt employees meet expectations to work additional hours as required to meet facility needs and project deadlines.
- Accepts responsibility for professional growth and development of self and attends all mandatory facility in-services and staff development activities as scheduled.
- Maintains professionalism and confidentiality of facility employees and clients.
- Performs other duties as assigned.
EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:
- Minimum of ten years of progressively responsible healthcare quality, patient safety, clinical quality, performance improvement, or related leadership experience, including at least five years in senior or executive leadership.
- Significant leadership experience within behavioral healthcare required, with substantial experience in substance use disorder treatment strongly preferred and experience across both acute psychiatric and SUD environments preferred.
- Demonstrated success leading Quality and Patient Safety across a complex multisite and multistate healthcare organization required, preferably with responsibility spanning five or more states and a geographically dispersed facility portfolio.
- Demonstrated experience building, transforming, or significantly enhancing enterprise Quality and Patient Safety programs, systems, infrastructure, and operating practices.
- Advanced experience with healthcare quality analytics, including development and interpretation of executive dashboards, trend analysis, identification of performance variation, and translation of data into improvement strategies.
- Demonstrated experience leading significant patient safety and performance improvement initiatives and producing measurable and sustained improvements in clinical outcomes.
- Experience working collaboratively with executive leadership, medical leadership, nursing, clinical services, operations, regulatory, compliance, risk management, and technology functions.
- Experience interacting with the board of directors, executive committees, medical staff leadership, regulatory agencies, and accreditation organizations strongly preferred.
- Experience with healthcare quality and performance improvement methodologies such as Lean, Six Sigma, PDSA, Model for Improvement, root cause analysis, failure mode and effects analysis, or comparable methodologies preferred.
- Recent experience should include direct operational leadership of healthcare quality functions rather than experience primarily limited to consulting, surveying, or advisory responsibilities.
LICENSES/DESIGNATIONS/CERTIFICATIONS:
- Advanced degree in healthcare, clinical, behavioral health, healthcare administration, public health, or a related discipline required.
- MD, DO, PsyD, PhD, MPH, MHA, MBA, MSN, MSW, APRN, or other relevant advanced degrees may be considered based upon the candidate's overall clinical and healthcare quality experience.
- If the candidate's terminal degree is a PhD, a Clinical Psychology degree and background is strongly preferred.
- Working knowledge of CMS, The Joint Commission, CARF, state licensure requirements, and other regulatory and accreditation standards applicable to behavioral healthcare required.
- Certified Professional in Healthcare Quality CPHQ certification preferred.
- Project Management Professional PMP certification or comparable formal project management certification preferred.
- Lean Six Sigma, Certified Professional in Patient Safety, or other recognized quality, patient safety, or performance improvement credential preferred.
SUPERVISORY REQUIREMENTS:
- Ten or more years’ supervisory/management experience required, preferably in behavioral health.
WORK LOCATION:
- This position is on-site at the Company’s headquarters in Franklin, TN and is not a remote position.
Veterans and military spouses are highly encouraged to apply. Summit BHC is dedicated to serving Veterans with specialized programming at our treatment centers across the country. We recognize and value the unique strengths of the military community in supporting our mission to serve those who have served.