Behavioral Health Senior Director of Risk, Quality and Compliance

POSITION SUMMARY:

The Senior Director of Risk Quality and Compliance is responsible for developing implementing and overseeing comprehensive risk management quality assurance and compliance programs within the BMC Health System. This leadership role ensures the organization adheres to state and federal regulations fosters a culture of safety and continuous improvement and aligns operations with industry standards to deliver highquality care in a behavioral health setting.

Position: Behavioral Health Senior Director of Risk Quality and Compliance

Department: Chief Quality Officer

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

• In conjunction with the Department of Quality at Boston Medical Center (BMC) the Senior Director of Risk Quality and Compliance is responsible for the overall management of potential risks and liabilities primarily within the Brockton Behavioral Health Center (BBHC) with extension of these practices across the BMC Health System (BMCHS) as clinical integration grows. The senior director serves as a role model displaying behaviors that support a strong culture of safety. The Senior Director of Risk Quality and Compliance responds to patient harm events learns from individual cases identifies risk trends and actively educates leaders administrators clinicians and staff regarding methods to maximize patient safety and simultaneously reduce professional liability claims.
• This role provides assistance to leadership and staff in complying with Joint Commission (TJC) HIPAA Bureau of Substance Abuse Services (BSAS) Center for Medicare/Medicaid Services (CMS) and Department of Public Health/Mental Health (DPH/DMH) standards and other applicable laws as well as maintains current TJC DMH BSAS CMS other regulatory/supervisory organizations healthcare compliance and risk management skills through continuing education.
• This position requires onsite presence 5 days a week and oncall coverage with 24/7 BMCHS behavioral health support.

Responsible for the daytoday coordination of internal adverse event reporting system as a critical component of the BMC hospital safety program:

• Receives and reviews adverse event reports.
• Provides advice consultation recommendations and support to hospital and professional staff in responding to adverse events.
• Initiates discussion of adverse events and facilitates the activation of immediate mitigation strategies documents plans and organized future discussions related to event as needed (e.g. followup meetings RCA/ACA etc.)
• Manages and leads investigation related to adverse events including interviewing staff and reviewing medical records for evaluation of clinical improvement and regulatory/liability reporting.
• Maintains the adverse event reporting database (RL Solutions) for tracking patient safety events. Uses this database to identify trends and opportunities to improve patient safety and health equity gaps and presents this information to center leadership regularly to initiate improvement strategies.
• Works across the BMCHS system closely with local behavioral health nursing and physician leadership. And assists the Human Rights Officer (HRO) on patient safety issues and patient/visitor complaints in accordance with DMH regulations.
• Manages intake of adverse hospital and patient event reports:
  • Ensures appropriate and timely followup to adverse events to mitigate immediate threats to safety and address other serious issues.
  • Refers cases as directed to the BMCHS Captive insurer to minimize legal/financial liability.
• Helps ensure compliance with laws rules and regulations concerning patient care including those mandated by state federal agencies and accrediting bodies.
• Communicates timely with facility leadership about the arrival of announced or unannounced regulatory site visits to ensure survey readiness.
• Communicates timely with facility leadership about the conclusion and finding of regulatory site visits.
• Assists in review and development of policies and procedures in relation to Compliance and Risk Management.
• Actively participates in clinical case reviews and case learning committees at each BMC facility.
• As clinical integration evolves will optimizes the committee structure across the three facilities which may include system level oversight and governance.
• Keeps abreast of legislative and regulatory activities related to regulatory compliance and patient safety.
• Maintain a central database for risk quality and compliance documents to ensure timely retrospective investigation as needed.

Risk Management Responsibilities

• Identify assess and mitigate risks to ensure patient safety employee wellbeing and organizational integrity.
• Develop and implement risk management policies procedures and training programs.
• Oversee incident reporting investigation and resolution processes ensuring timely and effective followup.
• Serve as the systems primary liaison with legal counsel and insurance providers regarding riskrelated matters.
• Oversee the review and manage the reporting of adverse events ensuring submission to DMH within 24 hours.
• Identify trends and collaborates with local leadership and BMC Quality and Patient Safety Staff and other system clinical teams as needed to design processes to prevent medical error and reduce loss.
• Provide feedback to reporters regarding investigation and corrective actions and ensures followup and monitors completion of corrective actions.
• Periodically report on risk management matters and prepare reports for various committees and stakeholders as assigned.
• Responsible for ensuring that all information necessary to prepare for the defense of claims is collected and properly maintained in a timely manner including the preparation of reports of investigation.
• Review aggregate adverse events as well as other hospital information to identify problem and riskprone activities procedures and services and provide recommendations to leadership about mitigation of risk in the future.
• Facilitate organization and operationalization of collaborative risk review activities on assigned cases.
• Provides backup to site HROs and addresses patient and visitor complaints when the HRO is unavailable.

Quality Assurance and Performance Improvement

• Lead the development and implementation of the systems Quality Assurance and Performance Improvement plan utilizing key indicators of quality improvement from NDNQI CMS TJC and other performance metrics such as HBIPS and other facilityspecific quality goals and initiatives.
• Take initiative in the development of key quality and performance dashboards and utilize data analytics to monitor performance metrics identify trends and implement evidencebased interventions.
• Organizes and leads Kaizen activities as needed Kaizen or continuous improvement isa business philosophy that involves employees at all levels of a company to make regular incremental improvements to goal is to eliminate waste and redundancies and to make jobs safer more fulfilling and less tiring.
• Utilizes Six Sigma strategy for performance improvement.

Regulatory Compliance Responsibilities

• Manage reporting to external regulatory agencies including DPH DMH and TJC and coordinate unannounced DMH/TJC/CMS hospital surveys.
• Oversee regular audits and accreditation surveys ensuring compliance with DPH DMH and TJC/CMS standards and other regulatory bodies.
• Operate as the survey coordinator for the system developing effective working relationships with accreditation and regulatory agencies i.e. TJC DPH DMH and CMS.
• Responsible for all aspects of the plan to ensure continual readiness with the regulatory compliance and accreditation requirements of the TJC DPH DMH and CMS. This includes but is not limited to:
  • Development coordination and implementation of the continual readiness plan
  • Ongoing assessment of the continual readiness plan identification of needed improvements and preparation and implementation of plans to achieve needed improvements
  • Identification of risks for both emerging and established standards
  • Mock surveys and reviews
  • Development of remedial action plans
  • Responding to agency requests for revision and corrective action plans
  • Organizes monitors and maintains a central database of current and historical corrective action plan supportive data to include but not limited to supporting documents such as attestations education policy revisions etc.

Routinely report on risk and compliance matters and prepare reports for various committees and stakeholders.

JOB REQUIREMENTS

REQUIRED EDUCATION AND EXPERIENCE:

Graduate degree in healthcare/related field or equivalent in training/experience required

Doctorate strongly preferred.

PREFERRED EDUCATION AND EXPERIENCE (If none please enter N/A):

Requires at least 8 years of clinical care/healthcare experience. Minimum of 2 years in either regulatory compliance or risk management. Behavioral health and crisis prevention experience required.

CERTIFICATIONS LICENSES REGISTRATIONS REQUIRED (If none please enter N/A):

N/A

CERTIFICATIONS LICENSES REGISTRATIONS PREFERRED (If none please enter N/A):

CPHRM preferred RN preferred

DMH HRO training to be completed upon hire

Six Sigma Black Belt preferred

KNOWLEDGE SKILLS & ABILITIES (KSAs) (If none please enter N/A):

• Knowledge of behavioral health regulations DMH DPH CMS and TJC standards preferred; knowledge of medical malpractice healthcare law and healthcare terminology preferred.
• Must have interpersonal skills necessary to deal effectively with administrative and clinical leadership staff clinical chairpersons and other healthcare professionals.
• Ability to effectively interview individuals and groups from diverse professional backgrounds.
• Ability to maintain confidentiality and handle matters of sensitive nature.
• Ability to collect event information and organize into a coherent narrative.
• Basic command of data management and analysis required.
• Highly selfmotivated. Ability to manage multiple projects simultaneously and adhere to work deadlines.
• Ability to inspire trust and be seen as someone who provides support and assistance.
• Excellent verbal and written communication skills.
• Excellent presentation skill including ability to speak before large audiences and prepare and provide presentations.
• Excellent computer skills including Microsoft Office; ability to learn new computer applications such as adverse event reporting software (RL Solutions).
• Occasionally needed to work irregular hours or additional hours for oncall purposes.
• Demonstrates flexibility and adaptability as role may evolve e in a changing environment.

Equal Opportunity Employer/Disabled/Veterans