Director of Quality, Risk & Compliance (Pontiac)

Pontiac General Hospital is seeking a hands-on, strategic Director of Quality, Risk & Compliance to lead quality, patient safety, and regulatory functions within a growing behavioral health hospital.

This is a highly visible leadership role at a pivotal time of expansion. With plans to significantly increase census and scale operations, the Director will have the opportunity to build and strengthen systems, implement best practices, and drive a culture of safety and continuous improvement across the organization.

Reporting to executive leadership and partnering closely with the Chief Nursing Officer, this individual will play a key role in shaping quality outcomes and operational excellence.

Why This Role

• High-impact leadership role with direct access to executive leadership and the Board
• Growth environment with rapid expansion in patients and staff
• Collaborative, non-punitive culture focused on safety and improvement
• Entrepreneurial setting with the ability to build and influence systems
• Opportunity to help the hospital evolve into a Center of Excellence

Key Responsibilities

• Lead all aspects of Quality, Risk Management, and Compliance
• Oversee and evolve the QAPI program, including KPI tracking and performance improvement initiatives
• Ensure compliance with CMS and Joint Commission standards, lead survey readiness and audits
• Direct incident reporting, investigations, and root cause analyses (RCAs)
• Identify trends, mitigate risk, and implement corrective actions in real time
• Drive data collection, analysis, and reporting to inform decision-making
• Partner cross-functionally with clinical and operational teams to improve processes
• Provide education and training on quality, safety, and regulatory requirements

Ideal Candidate

• 3–5+ years of experience in Quality, Risk, Compliance, or Performance Improvement in a hospital setting
• Strong understanding of behavioral health operations (required; must have BH exposure)
• Experience with QAPI, regulatory compliance, audits, and data analysis
• Familiarity with CMS and Joint Commission standards
• Proven ability to lead investigations and drive process improvement

Preferred:

• Clinical background (RN or similar)
• Advanced degree
• Experience with restraint/seclusion practices
• Knowledge of Michigan Mental Health Code and CON

Culture & Fit

• Self-starter who operates with urgency and accountability
• Collaborative and solutions-oriented (non-punitive approach to quality)
• Comfortable in a fast-paced, growth environment
• Strong communicator with a business-minded perspective

Organizational Snapshot

• Independent, for-profit behavioral health hospital
• Licensed for 124 beds (Adult, Geriatric, IDD)
• Current census ~20; scaling to 80–100 patients
• Team growing from ~60 to 170–200 FTEs
• Supported by engaged and accessible leadership