Director (OBH), Behavioral Health Quality Assurance

				Overview:

Coordinate and implement the Quality Improvement activities of the Department of Psychiatry including Incident Review, Quality Assurance, and Utilization Review for both the Inpatient division and the entire Ambulatory Care programs.

Responsibilities:

* Directs the psychiatry department's QA program; preparing and developing QA policies and updating policies as necessary. 
* Provides education to department staff in all QA and PI activities of the department.
* Performs incident investigation, coordination and supervision.
* Integrates the QA activities of the department with the hospital core business.
* Reviews, analyzes and coordinates the investigation of incidents; prepare worksheets and minutes; communicate with regulatory agencies regarding incidents.
* Develops and completes the departments' "dashboard" for patient satisfaction and other metrics as required.   
* Prepares agenda and minutes, coordinates and analyzes data for the QA meetings; Prepares and disseminates the required QA data reports to the hospital community.  
* Coordinates the activities of the PI teams of the department.
* Develops QA measures responsive to required corrective action for deficiencies identified by the regulatory agencies.
* Participate on the QA and cabinet Committees.
* Develops and coordinate the FMEA activities for the department.
* Coordinates the JCAHO preparation for Opioed Treatment and the conclusive action reporting required by the facility.
* Conducts QA audits to assess areas of improvement and develop processes for improvement.
* Assess the departments QA adherence and compliance to hospital wide and regulatory organizations (JCAHO, CMS, DOH, and others), mandates on a continuous basis. 
* Remains current on all QA/regulatory compliance issues. 
* Performs other duties as required.

Qualifications:

Position Requirements:

* Minimum Masters Degree required. PhD/M.D. preferred.

Experience:

* Minimum three (3) years job related experience.

Licenses, Certifications:

* CPHQ certification highly desirable.

Knowledge, Skills and Abilities:

* Thorough knowledge of Q/A processes and procedures. 
* Excellent verbal/written/communication skills.
* Familiar with the operations of hospital departments.
* Understanding of hospital policies and procedures.
* Basic computer knowledge.
* Excellent creative writing skills

 Physical Demands:

* Involves standing, walking, sitting, talking, hearing and bending. 
* May include some repetitive motions. 
* Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising patient care.

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The Brookdale Hospital Medical Center