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.

1. Utilization Management

• To appropriately evaluate and coordinate a patient's need for ancillary services, specialty services and referrals, assuring appropriate utilization based on practice guidelines and clinical judgment.
• To evaluate systems for tracking appropriate follow up of abnormal diagnostic studies and the use of preventive health measures. To incorporate case management guidelines in order to optimize utilization of the services and decrease barriers to care.

1. Risk Management

• To develop a comprehensive data collection system through medical information systems, review of medical records and client complaints to assure that the medical services are provided in an acceptable, efficient and sensitive manner.
• To create a member advisory committee to give feedback on clinic services and promotes communication between providers and members.
• To evaluate case management and tracking of patient follow up for preventive services, abnormal lab/procedure results, adverse outcomes and specific diseases or service indicators in order to direct the Kedren Health towards a specific review of clinic or provider practice.
• To establish and maintain basic elements of risk management (such as documentation, charting procedures, medical records, case management, communication systems, clinical supervision and maintenance of confidentiality) by means of, but not limited to:

1. Audits

To address specific aspects of the patients (members)' interface with the clinics, including access, service availability, the referral process, efficiency, communication and continuity. To adopt standard templates for internal evaluation of these service elements.

To collect and analyze data to compare performance to standards, implement interventions to improve performance and evaluate effectiveness of interventions.

To ensure the availability of appropriate primary care and specialty providers and to consider any unique needs and preferences of the patients (members) in arranging appointments and facilitating access.

To monitor compliance with access standards.

• Preventive Care Appointments 30 Days
• Routine Appointments 14 Days
• Urgent Care Appointments 24 hours
• Emergency Care Immediate

1. Patient Satisfaction

To collect and review survey data from patients (members) to be aware of patient-perceived concerns and to incorporate specific trends of problems into other review processes that are part of the QMP (CQI, Risk Management, Peer Review, and Utilization Management).

1. Peer Review

To review medical records using a Kedren Health standardized tool in order to identify concerns in the provision of medical care, utilization, or documentation by clinic staff.

To establish inter-provider consistency and adherence to baseline uniform standards in the medical records and in the care of patients (members). To use disciplinary action when needed to maintain standards of care and service.

1. Provider Retention and Member Retention

To collect and review input from Kedren Health providers to be aware of any concerns raised by clinical staff. To respond appropriately to such information and ultimately maintain provider satisfaction.

To collect and review input from Kedren Health members to be aware of any concerns raised by membership. To respond appropriately to such information and ultimately maintain member satisfaction.

1. Client Complaints

To develop and implement standardized forms and procedures for the identification and resolution of complaints by internal and external clients (patients, providers, clinic staff, and specialists).

To identify problems and take corrective action, as applicable, to improve the quality of care provided by clinical staff.

1. Credentialing/Re-credentialing

To ensure that all licensed or certified health care practitioners are licensed, registered or certified by the State of California in accordance with credentialing requirements.

To give final approval or denial for providers credentialing or re-credentialing whose qualifications have been verified.

1. Clinical Practice Guidelines

To adopt and maintain optimal care to achieve best practices. To utilize such guidelines as a tool in reviewing practice patterns, treatment plans, referrals, and establishing an approach to reduce provider variability thus standardizing the quality of care.

1. Policies and Procedures

To ensure the delivery of high-quality patient care and service, including preventive medicine, in a safe and cost-effective manner using consistent and comprehensive internal guidelines.

To monitor the effectiveness and compliance with such policies and procedures through other Kedren Health QMP activities.

To develop standardized physician assistant supervisor contracts and nurse

practitioner process-oriented protocols that remain timely, comply with state regulations and support a high standard of care.

1. Patient Education

Assist clinics in adopting and maintaining culturally and linguistically appropriate patient education materials.

1. Emergency Health Care

The Director of Quality Management is responsible for the overall direction, coordination and implementation of the QI Program for California Department of Healthcare Services licensed acute psychiatric hospital. The primary role will be the assurance of the organization's compliance with care standards and quality key performance indicators. This will include the collection, management and analysis of quality data and the preparation of quality reports. Practical knowledge of tools and techniques of Continuous Quality Improvement (CQI), including analysis and interpretation of data using computer-based electronic health records data collection systems is essential. The Director of Quality Management must be familiar with the processes associated with attainment and maintenance of JACHO accreditation. The Director of Quality Management will participate in and assist in preparation for all clinical audits and surveys at the local, state, and federal level inclusive of those such associated with various health plans, and may interface with personnel from these regulatory bodies. Furthermore, the Director of Quality Management will assist in the provision of data needed for grant attainment and those associated with hospital funding submissions. The Director of Quality Management may assist the Compliance officer or other QI staff with necessary follow-up as related to Root-Cause-Analysis (RCA) investigations and will assist in the devising, implementation, and monitoring of corrective action plans, as applicable.

MINIMUM QUALIFICATIONS REQUIRED FOR THIS POSITION:

• Bachelor of Nursing degree or Master in Public Health preferred, yet individuals with strong related experience in leading a quality improvement program may be considered
• Minimum 2-3 years of progressive experience in Quality Improvement in a healthcare facility, preferably with a federally qualified health center doing business in California.
• Project management skills
• Must demonstrate integrity, sound judgment, demonstrated leadership skills, and strong interpersonal skills.
• Must be able to approach staff about quality issues with tact and diplomacy.
• Experience working with disadvantaged populations helpful and knowledge of health disparities highly desired.
• Excellent oral and written communication skills needed, strong organizational ability required.
• Outstanding skills in data collection, analysis, and presentation.
• Experience in the use of spreadsheets (e.g. Excel) for QI-related data management and display
• Current Basic Life Support (BLS) certification for Healthcare Providers
• Current CPR Certification
• Project management, time management, team-building, analytical, and facilitation skills.

GENERAL STATEMENT OF FUNCTIONS:

1. Assists in the development, monitoring, and presentation of internal quality measures and initiatives

1. Coordinating tracking and reporting of clinical outcomes, and follow-up of corrective action plans

1. Responsible for developing methods for data collection and extracts data, as required

1. Assists with coordination of quarterly QI Meetings

1. Prepares QI reports and statistics

1. Participates in staff and management meetings as they relate to QI activities

1. Provides in-service training top provider and non-provider staff in the area of quality improvement

1. Reviews QI tools and surveys and provides technical assistance to staff

1. Assist with annual UDS and HRSA reports

1. Attends conferences and training sessions, as requested

1. Investigation of any claims against the organization, including malpractice or failure to adhere to recommended safety or institutional standards

1. Develops performance improvement targets across the organization.

1. Prepare written reports, assemble data, and create charts and graphs representing key performance indicators and other imperative data

1. Accepts other job duties as delegated

STANDARDS OF PRACTICE:

Must adhere to the regulatory and clinical standards of clinical care and documentation as set forth by health plans, as well as local, state, and federal governing bodies.