Regnl Mgr, Continued Qual Impr at Westchester Medical Center – Valhalla, New York

Job Summary: The Continued Quality Improvement Regional Manager supports the Senior Director in the development and management of quality and safety programs and initiatives across the behavioral health and addiction service continuum of care at Mid-Hudson Regional Hospital and Health Alliance of the Hudson Valley. Responsibilities include collecting and reporting data, analyzing metrics in collaboration with program staff, reviewing patient events, evaluating policies and processes to identify opportunities for improvement, recommending structure, process and outcome measures, facilitating core measure data collection and reporting, supporting process change and documenting and reporting results. The incumbent is also responsible to participate in incident analysis, provide staff education and training such as patient safety, support the Director in regulatory compliance continued readiness initiatives, and survey management and follow-up activities.

Responsibilities:

• In collaboration with the Senior Director of Quality - BHAS, implements routine, standardized audits of medical record documentation, environment of care, and other audits as required for inpatient mental health, inpatient medical detoxification, inpatient substance abuse rehabilitation, psychiatric ED, outpatient MH and outpatient substance abuse treatment programs with the goal of facilitating standards compliance, quality of care monitoring and problem identification.
• Ensures program specific publication of important indicator dashboards in a format that facilitates clear understanding of the data to aid in BHAS management and leadership decision making
• In collaboration with program staff and aligned with BHAS quality improvement goals, assists in the organization and implementation of performance improvement projects related to structure, process and outcome quality measures, justified by patient quality of care and safety needs, compliance mandates, evidenced-based practice, indicator data analysis of declining trends, staff productivity, and fiscal prudence.
• Provides support and direction to program-based Quality Improvement Teams (QIT’s). Ensures that QIT metrics are collated and presented to the Behavioral Health Quality Council in a standardized and professional manner. Participates in committees, task forces, and work groups as assigned by the Director of Quality – BHAS.
• Provides education to all disciplines, as directed, to aid in hardwiring quality and safety initiatives into the daily practice of program staff.
• In conjunction with the Department of Quality, Risk Management, and BHAS, develops and refines Midas data dictionary and recommends program specific track and trend reports.
• In accordance with the BHAS Performance Improvement Plan, assists it the development of statistically sound metrics and data collection methodologies to provide objective, aggregate data for BHAS and Quality staff review, analysis and improvement actions
• Provides support to the Director of Quality – BHAS in developing and implementing data collection strategies to achieve EMR data mining and timely CMS reporting of required Inpatient Psychiatric Facility Core Measures.

• Participates in the routine screening of incidents and occurrences across all program sites to determine the next appropriate level of reporting, follow up, documentation, and course of action.
• Participates in the weekly Incident Review Committee and contributes to case analysis and action planning to enhance the quality of patient care and to prevent recurrence of incidents that either resulted in patient harm or serious risk of harm.
• Supports that BH Risk Managers/investigators to track and trend incident types and to analyze the effectiveness of corrective actions.
• Documents IRC case review findings and recommendations for corrective action via written confidential minutes to ensure accurately recording of outcomes and recommendations.
• Maintains an open case corrective action tracking report to ensure that all recommended corrective actions have been implemented.
• Conducts Root Cause Analyses and clinical case reviews, investigations and confidential staff interviews, as assigned.
• Works in collaboration with hospital managers and staff to ensure regulatory compliance and continued readiness for surveys including, but not limited to Centers for Medicare and Medicaid (CMS), Das Norte Veritas (DNV), The Joint Commission (TJC), NYS dDepartment of Health (DOH), NYS Office of Mental Health (OMH), NYS Justice Center, Office of Alcohol and Substance Abuse Services (OASAS), Commission on Accreditation of Rehabilitation Facilities (CARF).
• Under the direction of the Senior Director of Quality - BHAS, implements program-specific continued readiness initiatives by conducting staff education, tracers and rounding.
• In collaboration with members of the Department of Quality and Safety and as directed, provides escort to surveyors on facility inspections, documents surveyor guidance, recommendations and actions, ensures document control in coordination with the Command Center, and provides support and guidance to program staff during the survey process.
• Survey Follow-up – Tracks the completion of corrective action plans via routine deliverable meetings with program staff, maintains organized files of corrective action and measure of success documents, and facilitates report and data presentation to BH Quality Council, WMC Quality Council, and the Board of Directors Quality Committee.
• Participates in department specific and hospital-wide patient safety initiatives with particular relevance to behavioral health and addiction service patients and staff.

• In collaboration with program staff and the Senior Director of Quality - BHAS, conducts environment of care safety rounds, ensures that finding are collated and presented to behavioral health and environment of care quality councils, and recommends corrective action.
• Participates in patient safety risk- benefit analysis tools in accordance with industry standards, and evidence-based practice and regulatory requirements.
• In accord with hospital initiatives, actively supports the implementation of a culture of safety by encouraging staff to discuss safety concerns with supervisors and report patient incidents via Midas and escalation protocols. Foster safety culture in every day actions by influencing staff behaviors, attitudes and understandings about the importance of patient safety.
• Performs other duties as required.

Qualifications/Requirements:

Experience: Either:

Bachelor’s Degree in a health/mental health related discipline with three years’ experience in medical record review, incident management or reporting, quality data analysis and presentation, and survey readiness experience: or

A bachelor’s degree in a health/mental health related discipline with seven years’ of supervisory or managerial experience in a behavioral health program, 2 years of which must have included responsibility for quality oversight; or

A Master’s degree in a health/mental health related discipline three years of supervisory or managerial experience in a behavioral health program, one of which must have included responsibility for quality oversight. Experience in large academic medical center or health system preferred.

Education: Either:

•Bachelor’s Degree in a health/mental health related discipline with three years’ experience in medical record review, incident management or reporting, quality data analysis and presentation, and survey readiness experience: or

•A bachelor’s degree in a health/mental health related discipline with seven years’ of supervisory or managerial experience in a behavioral health program, 2 years of which must have included responsibility for quality oversight; or

•A Master’s degree in a health/mental health related discipline three years of supervisory or managerial experience in a behavioral health program, one of which must have included responsibility for quality oversight. Experience in large academic medical center or health system preferred.

Licenses / Certifications:

Other: Thorough knowledge of quality improvement functions as they relate to inpatient and outpatient behavioral health and addiction treatment programs. Good knowledge of the operational processes, routines and functions of a large hospital, strong knowledge of regulatory agencies and standards related to mental health and addiction services), ability to develop audit tools, collect, organize and analyze data, draw conclusions and prepare reports. Good ability to conduct a quality review of behavioral health medical records. Ability to maintain effective working relationships with all levels of staff in an environment that supports transparency, quality care, patient safety, and service excellence. Ability to communicate effectively both orally and in writing. Ability to comprehend and carry out written and oral instructions. Ability to effectively use multiple Microsoft Office computer applications and database software to carry out work functions (Excel and Midas experience preferred). Ability to read, write, speak, understand and communicate in English sufficiently to perform the essential duties of the position, sound professional.

Special Requirements: