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Bournewood Health Systems · 2 weeks ago

Quality Assurance and Compliance Director

Chestnut Hill, MA

Full-time

Onsite

Lead/Staff, Director/Executive

3+ years exp

Bournewood Health Systems is seeking a Quality Assurance and Compliance Director to lead the hospital’s Quality Assessment and Performance Improvement (QAPI) and Compliance Programs. This role ensures the hospital meets regulatory standards and promotes continuous regulatory readiness while collaborating with leadership to enhance patient safety and quality improvement initiatives.

Health Care

Responsibilities

Develop, implement, and manage the hospital’s QAPI and Compliance Programs in alignment with regulatory and accreditation standards

Ensure the integration of quality and compliance activities into all levels of the organization

Ensure risk management, patient safety, and compliance data are integrated into QI reporting

Maintain documentation for accreditation readiness (Joint Commission, CMS, BSAS, DMH), including Measures of Success, FMEAs, and audit tools

Coordinate and lead Quality and Compliance Committees, and co-lead Patient Safety Committee. May co-lead other committees as assigned

Ensure ongoing readiness for TJC, DMH, BSAS, and CMS surveys and inspections

Serve as primary liaison during all regulatory surveys, audits, and inspections

Monitor changes in laws, regulations, and standards, and update hospital policies and practices accordingly

Collect, analyze, and report data related to clinical outcomes, patient safety, and performance indicators

Conduct root cause analyses, identify trends, and facilitate corrective action planning

Provide regular quality and compliance reports to hospital leadership and the Governing Body

Develop and deliver staff education on quality improvement, patient safety, and compliance standards

Support department leaders in understanding and applying regulatory and accreditation requirements

Oversee the hospital’s incident reporting, investigation, and follow-up processes

Ensure timely reporting to regulatory agencies when required

Collaborate with leadership on risk reduction strategies

Maintain and review hospital policies and procedures for regulatory alignment

Ensure timely policy updates and staff notification

Demonstrates professionalism, clarity, and respect in all forms of communication

Communicate effectively with staff, leadership, patients, and regulatory agencies

Maintains open, collaborative communication across departments to support transparency and teamwork

Demonstrates appropriate communication and composure in challenging or high-pressure situations, including when addressing compliance findings, staff concerns, or regulatory interactions

Provides constructive feedback and education to staff in a supportive and solution-focused manner

Ensures communication of quality and compliance data is accurate, timely, and easily understood by diverse audiences

Adheres to all hospital policies and procedures

Ensures compliance with all applicable standards, including TJC, DMH, BSAS, and CMS

Maintains confidentiality in accordance with HIPAA and hospital standards

Reports any suspected violations of compliance or safety standards immediately

May act as Privacy Officer and assist in HRO complaint resolutions

Qualification

Quality ManagementRegulatory CompliancePerformance ImprovementBehavioral Health KnowledgeData Reporting SystemsAnalytical SkillsProject ManagementMicrosoft Office SuiteCommunication SkillsLeadership SkillsProblem-Solving SkillsInterpersonal SkillsConfidentiality ManagementTeam Collaboration

Required

Current Massachusetts licensure as a Registered Nurse (RN), Licensed Practical Nurse (LPN), or Licensed Independent Clinical Social Worker (LICSW) required

Bachelor's degree in Nursing, Social Work, Health Care Administration, or related field required

Minimum of three (3) years of progressive experience in quality management, regulatory compliance, or performance improvement in a healthcare setting

Comprehensive knowledge of The Joint Commission (TJC), Massachusetts Department of Mental Health (DMH), Bureau of Substance Addiction Services (BSAS), and Centers for Medicare & Medicaid Services (CMS) standards and reporting requirements

Strong analytical, organizational, and project management skills

Ability to interpret regulations and accreditation standards and translate them into practice

Excellent written, verbal, and interpersonal communication skills

Proficiency in Microsoft Office Suite and data reporting systems