Director of Quality Management - Behavioral Health

About the role

Marketing Statement Kings County Hospital Center has a rich legacy for its pioneering role in medicine. Today, with over 625 beds, our hospital remains on the cutting edge of technology and provides the most modern procedures with state-of-the-art equipment. Built in 1831 as a one room infirmary for publicly supported care of the sick, Kings County Hospital Center continues to be a leading healthcare facility whose mission is to provide care to everyone regardless of their ability to pay. The hospital provides a wide range of health services, and specialties are offered in all fields of modern medicine. More than 200 clinics provide a wide array of ambulatory care services. At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.

Responsibilities

• Designs, develops, and implements effective strategies and programs throughout the health care setting focused on improving quality, patient experience, and population health outcomes and reducing the cost of patient care.
• Monitors the effectiveness of the department’s activities and all quality management programs across the health care setting and facilitates successful evaluation of health care quality standards in line with governance provided by external regulatory agencies, as well as by other entities.
• Coordinates the collection and analysis of all data related to quality indicators and utilizes findings to drive improvements, mitigate risks, and to increase the level of care within the System.
• Oversee policy development and management for the Behavioral Health Service
• Serves as both principal advisor and key resource to senior leadership, clinical staff, and other appropriate parties on matters pertaining to quality management techniques and systems, and presents findings of assessments, analyses, and safety incidents to various agencies, executives and/or senior managers.
• Advises on upcoming regulatory changes and readiness
• Responsible for oversight of all processes necessary to meet regulatory standards from various governing bodies and accrediting agencies.
• Maintains readiness for unannounced agency visits and participates in various regulatory agency surveys.
• Serves as regulatory liaison, specifically as it relates to departmental performance and the creation of action plans to assist leadership in communicating newly adopted approaches in reaching medical excellence.
• Investigates incidents involving patient care and safety, and makes reports to the appropriate public health and regulatory agencies.
• Presents findings to related parties and incorporates new findings into affected procedural tools or programs.
• Makes recommendations relating to the prevention of such incidents and to determine quality control measures to foster a culture of safety for patients, staff, and visitors.
• Ensure data collection systems are developed and in place, utilizing Epic EMR and all regulatory body portals (NGS, MHPD, etc.)
• Maintain and analyze data dashboards to drive performance improvement actives
• Responsible for timely submission of all regulatory body data and survey requests (including NICS)
• Oversight of all PIP’s, POCAS, and licensure requirements to ensure good standing
• Collaborate with Hospital-Wide regulatory office
• Ensure EPIC EMR developments support service and regulatory needs
• Work closely with Chief of BHS to ensure Risk management, Training and Staff Development & Quality are working together to address trends in quality and safety.
• Lead Quality Council and all related actives
• Develop IT solutions for gathering, analyzing data to support management and leadership within BHS
• Drive UR/UM transformation with BHS senior leadership.
• Supervise and/or facilitate office administration and office record keeping activities.
• Assist with regulatory training requirements.
• Other duties as indicated.

Requirements

• Master’s degree from an accredited college or university in Quality Management, Hospital Administration, Health Care Administration, or in a related health care specialization; and five (5) years of experience in the development of organizational strategies and implementation of staffing plans, regulatory survey preparation and compliance, and in performance improvement and/or continuous quality improvement (CQI) initiatives in a hospital or health care setting, three (3) years of which must have been in a responsible administrative, managerial or supervisory capacity; or
• Bachelor’s degree in the