Job Summary:

• Under the general supervision of the enterprise-wide Director of Quality and Safety for Behavioral Health and Addiction Services (BHAS), the Continued Quality Improvement Manager supports the Director in the development and management of quality and safety programs and initiatives across MHRH's behavioral health and addiction service 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, 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 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 Statit 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.
• Maintains a NYS OMH/Justice Center Incident reporting log, in collaboration with the BHAS Risk Manager and monitors compliance with timely reporting requirements.
• 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 corrective action types to determine effectiveness of interventions.
• Documents IRC case review findings and recommendation 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.
• Participates in Root Cause Analyses and Failure Mode Effects Analysis committees, provides committee support as needed, conducts clini