Strength Through Diversity
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The Safety and Quality Manager is accountable for the incident investigation and reporting process, and identifying, assessing, reporting, educating and recommending solutions to quality improvement and risk management issues. This individual may also address educational, certification and competency issues for the staff, and coordinates the Joint Commission and other regulatory standards and related initiatives through interdisciplinary communication with leadership.
Roles & Responsibilities:
Accountable for incident investigation and reporting. Provides recommendations of quality improvement and risk management issue solutions. S/he supports excellence in the delivery of patient care services, patient management; the unit and clinical service objectives and the goals of the organization.
Oversees quality improvement projects for the department; serve as the subject matter expert on quality improvement models and knowledge.
Liaison with Office of Mental Health, Office of Alcoholism and Substance Abuse Services, and the Justice Center.
Collaborates with leadership staff to ensure that the highest expectations of regulatory and professional standards are met. S/he provides support to clinical leadership in the development of interdisciplinary standards relevant to the department.
Coordinates and co-chairs the monthly Incident Review Committee (IRC), Quality Improvement Committee (QI), and Morbidity and Mortality (M&M) meeting. Member of any additional committees focusing on safety and quality for the department.
Maintains, reviews and updates all specialty policies in accordance with hospital, professional and regulatory standards.
Identifies, responds to and investigates potential and actual risk management issues. Reports significant events to the appropriate regulatory agency and internal hospital staff. Tracks corrective action plans to completion.
Collaborates with other disciplines to identify opportunities for improving patient outcomes, to reduce future risk and to enhance customer satisfaction.
Assesses staff educational needs and develops training programs to address their needs. Provides individual and group education programs to meet corrective action goals; if applicable to specific department role, may be responsible for staff members to be appropriately credentialed, competent and have completed required educational programs.
May assist in the development of new educational programs based on professional standards, performance improvement data and regulatory agency (i.e., Joint Commission and the Department of Mental Hygiene) recommendations.
Oversees and supervises the quality improvement specialists of the department.
Works with site and system leadership to develop performance improvement programs/metrics that support safety and quality goals
Other related duties as assigned.
Participates in the department’s performance improvement activities.
Maintains patient/employee confidentiality in the management of information.
Observes System compliance policies
Adheres to departmental policies and procedures
Participates in the development of other staff members.
Meets regulatory, licensure and annual health assessment requirements.
Identifies learning strengths and needs.
Utilizes learning resources.
Uses individual and group supervision appropriately via ongoing discussion of client status, prioritization of tasks, problem-solving techniques, issues, and identification of reactions that impeded or facilitate services.
May be required to perform other duties as assigned or perform other duties when necessary.
Maintains a cooperative attitude by performing all duties, as assigned, in a pleasant and timely manner.
Functions as team member by willingly covering clients when needed and by maintaining an attitude of concern for the safety and well-being of other team members.
Display courtesy, tact and patience during interactions with all members of the hospital staff and extended community.
Demonstrates a professional, courteous, and respectful attitude in dealing with patients, families and significant others.
Master's Degree required (preferably in a Health related field)
3+ years' experience with a preferred minimum of 2 years in a clinical role and exposure to quality and safety management
Current NYS clinical licensure in a relevant field strongly preferred
Excellent verbal, written and interpersonal skills
Excellent organizational and decision-making skills
Demonstrated knowledge of quality management and/or Continuous Quality Improvemtn (CQI) principles and NYS Dept of Mental Health and Hygiene and JCAHO standards and regulations