Under the general supervision of the enterprise-wide Senior Director of Quality and Safety for Behavioral Health and Addiction Services (BHAS), the Regional Specialist, Continued Quality Improvement supports the Senior Director in the development and managementimplementation of quality and safety programs and initiatives across the behavioral health 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, investigating patient events, reviewing evaluating policies and processes to identify opportunities for improvement, recommending structure, process and outcome measures, core measure and other 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.
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 mental health 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 management and leadership decision making
In collaboration with program staff and aligned with 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.
Conducts Justice Center reported investigations and, under the direction of BH leadership, Risk Management and the Senior Director of Quality and Safety, submits required reports and documents to OMH, OASAS and the NYS Justice Center,
Maintains a NYS Justice Center Incident reporting log, ensures timely reporting of investigations and supporting documentation, and maintains confidential files, as applicable.
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.
Maintains an IRC dashboard 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 accurate 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 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 Department 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 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 in accordance with industry standards, 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.
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
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.
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.
WMCHealth is a 1,900-bed healthcare system headquartered in Valhalla, New York, with ten hospitals on eight campuses spanning 6,200 square miles of the Hudson Valley. WMCHealth employs more than 12,000 people and has nearly 3,000 attending physicians. From Level 1, Level 2 and Pediatric Trauma Centers, the region’s only acute care children’s hospital, an academic medical center, several community hospitals, dozens of specialized institutes and centers, a state of the art Telemedicine program, skilled nursing, assisted living facilities, homecare services and one of the largest mental health systems in New York State, today WMCHealth is the pre-eminent provider of integrated healthcare in the Hudson Valley.