Director, Quality, Risk & Safety

POSITION OBJECTIVE/SUMMARY:

The Quality Management (QM) Program in the acute psychiatric hospital is designed to monitor and evaluate the quality, appropriateness, effectiveness of and methods by which healthcare and services are delivered to Kedren patients. It is the critical fiduciary duty of the governing body and hospital staff of to commit to the continuous monitoring and evaluation process to achieve excellence in clinical care and all aspects of healthcare operations. This QM Plan ensures adherence to the standards of care, and outlines the methods by which Kedren and its staff achieve the vision of optimum care that is quality-based and safety-oriented for patients (members), their families, hospital insurance providers, and regulatory agencies. This quality management program is a systematic process with identified leadership, accountability, and dedicated resources, which uses data and measurable outcomes to determine progress toward relevant, evidence-based benchmarks.

QUALITY MANAGEMENT PROGRAM

The primary purpose of the hospital’s QM program is to promote excellence in patient care through continuous objective assessment of important aspects of care/service and the resolution of identified problems. An integral component of the QM program is to establish a systematic approach to addressing quality assessment and process improvement at Kedren. It is the goal of the QM Program to enhance the patients' health and safety, improve the members' perception of care, achieve optimal outcomes, enhance staff morale and improve organizational efficiency and effectiveness.

DIRECTOR OF QUALITY MANAGEMENT DUTIES AND EXPECTATIONS

The overall goal of the Director of Quality Management Assure high quality patient care and service for all clients and providers through routine monitoring of activities. Evaluate practitioner practices and professional performance objectively utilizing Quality Improvement methodology. Implement a comprehensive, integrated and responsive system of monitoring and evaluating the provision of care and services by the clinic staff and providers utilizing the following specific processes:

1. Continuous Quality Improvement

1. Utilization Management

1. Risk Management, consisting of:

1. Internal audits

1. Continuous quality improvement activities (including continuing medical education)

1. Patient satisfaction surveys

1. Peer review systems

1. Provider retention

1. Patient complaints

1. Credentialing standards

1. Establishment of practice guidelines (including preventive care guidelines)

1. Establishment of standardized policies and procedures

1. Patient education systems and activities

1. Utilization management

• Increase client and staff satisfaction with clinical services through timely identification, review and resolution of complaints.
• Identify problems that might impact, directly or indirectly, the provision of care or access to care through continuous monitoring of medical services. To develop reasonable and necessary measures to assess and improve the quality of care provided by all clinical staff.
• Assure that data, conclusions and recommendations are reported to the appropriate committee, department or individual and that these reports flow within designated feedback loops so that all persons involved both receive and send information. To assure that such flow of information is handled in an appropriate manner is consistent with the structure of the QMP and its committees.

The Director of Quality Management will ensure the oversight, implementation, direction, and adherence to Kedren’s objectives, scope and content of quality management activities, which include:

1. Continuous Quality Improvement

• To educate all providers, staff and administrators about the philosophy, procedures and practices of continuous quality improvement (CQI) at Kedren Health and its importance within the missions of standards of care of the participating clinics.

• To implement the Patient Centered Care Home Model as a process to improve clinical outcomes.
• To develop interdisciplinary teams who apply the Plan- Do-Study-Act cycles to determine effective improvement interventions towards target goals.
• To collect baseline data if possible to define pre-intervention performance and post- intervention results.
• To identify and evaluate specific clinical or service issues, using standardized indicators, benchmarks, and data collection to determine and implement a quality improvement plan. To develop monitoring tools (if applicable) and reassess the issues on a continuous, ongoing and meaningful basis.
• To incorporate primary care, specialty care, behavioral health and hospital/institutional referral services in the CQI process. To evaluate appropriate utilization of services.