Quality Manager, Behavioral Health

Job Details:

Job Summary:

The Quality Manager, Behavioral Healthsupports the Senior Director in the development and management of quality and safety programs and initiatives across WMC’s behavioral health continuum of care. 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, implementing performance improvement projects, facilitating development of corrective action planning, supporting process change and documenting and reporting results. The incumbent is also responsible to participate in incident investigation and 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, implements routine, standardized audits of medical record documentation, environment of care, and other audits as required for inpatient mental health, psychiatric ED, and outpatient MH 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 BH management and leadership decision making In collaboration with program staff and aligned with BH 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 Senior Director of Quality. 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 BH,, develops and refines Midas data dictionary and recommends program specific track and trend reports. In accordance with the BH 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 Recommends data collection strategies to achieve EMR data mining and timely CMS reporting of required Inpatient Psychiatric Facility Core Measures, and other selected suality and safety indicators. Participates in the routine screening of incidents and occurrences across assigned program sites to determine the next appropriate level of reporting, follow up, documentation, and course of action. Participates in the 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 the BH Risk Managers/investigators to analyze incident data trends, and recommend risk reduction strategies. Documents IRC case review findings and recommendations for corrective action via written confidential minutes to ensure accurately recording of outcomes and recommendations. Monitors corrective action tracking reports to ensure that all recommended 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), NYS Department of Health (DOH), NYS Office of Mental Health (OMH), NYS Justice Center, an others, as applicable Under the direction of the Senior Director of Quality, 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, maintains organized files of corrective action and measure of success documents. As requested, facilitates report and data presentations to BH Quality Council and other forums. 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, 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: • 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 three years’ of supervisory or managerial experience in a behavioral health program, 2 years of which must have included quality assessment and performance improvement activities; or • A Master’s degree in a health/mental health related discipline with two years’ experience in a behavioral health program, one year of which must have included quality assessment and performance improvement activities.

Experience:

Education:

Minimum: Bachelor’s Degree in a health/mental health related discipline

Licenses / Certifications:

Not required, CPHQ preferred

Other:

Thorough knowledge of quality improvement functions as they relate to inpatient and outpatient behavioral health 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, , 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 tocommunicate 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

Ability to read, write, speak, understand and communicate in English sufficiently to perform the essential duties of the position, sound professional judgment, tact, integrity, initiative, thoroughness, dependability, resourcefulness, and physical condition to adequately manage frequent travel between facility sites (on hospital grounds and off-site programs).