NYC Health Hospitals
Associate Director, Quality Assurance (Professional Standards Review)
NYC Health Hospitals, New York, New York, us, 10261
NYC Health + Hospitals/Jacobi is a 457-bed teaching hospital affiliated with the Albert Einstein College of Medicine. The facility has earned numerous Center of Excellence designations, accreditation, and recognition for its renowned Level 1 Trauma Center, Burn Center, Surgical Intensive Care Unit, regional Stroke Center, Snakebite Treatment Center, Breast Health Center, Bariatric Surgery Center, and Cancer Service. The facility also offers the region's only multi-person hyperbaric chamber, allowing up to nine patients to dive together at one time. Jacobi's Ambulatory Care Pavilion is a stunning complement to its inpatient acute care, allowing staff to provide patients with high-quality service in a modern, state-of-the-art environment.
At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.
Check us out online:
www.nychealthandhospitals.org
careers.nychhc.org
Docs4nyc.org
Work Shifts
7:00 A.M - 3:30 P.M 8:00 A.M - 4:00 P.M 8:30 A.M - 4:30 P.M 9:00 A.M - 5:00 P.M 10:00 A.M - 6:00 P.M
Job Description
Associate Director, Quality Assurance (Professional Standards Review) - Clinical Investigator/Risk Reduction Specialist
PURPOSE OF POSITION: This position encompasses supervisor, administrative and leadership functions. The responsibilities include both the performance of the functions of the risk management department as well as assisting in the coordination and supervision of the responsibilities and activities of Risk Management at NYC Health + Hospitals/Jacobi.
Unit Specific - CLINICAL/ADMINISTRATIVE:
1) Assists Director and Associate Director of Risk Management in the management, supervision and coordination of activities of the Risk Management Department at JMC.
2) Develops and maintains a collaborative relationship with the medical, nursing and ancillary departments within the institution to promote and to facilitate the principals of risk management and patient safety. Assists the Director and Associate Director in acting as a departmental liaison to the administrative and medical staff when staff request guidance on medical-legal questions and issues with risk management and regulatory implications for the corporation, facility, facility personnel and patients and their families.
3) Maintains a proficiency and working knowledge of applicable 405 regulations, NYC Public Health Law, HHC corporate policies and procedures, DOH regulations, NYPORTS criteria and Hospital policies and procedures.
4) At the direction of the Director utilizes analytical skills and medical knowledge to evaluate the litigation claims received in the department and identify issues with implications for future quality of care and patient safety.
5)Maintains working knowledge of departmental data storage systems and responsible for data entry into the on-line Occurrence reporting system (VOICE) for those cases investigated and reviewed by the Risk Reduction Specialist/Clinical Investigator.
6) Identifies cases that meet NYPORTS criteria, Joint Commission Criteria for Root Cause Analysis or internal review for quality/patient safety purposes. - Reviews cases reviewed by Departments to identify reportable/trackable cases. - Reviews cases referred from staff - verbally, AOD report, occurrence report, mortality review, etc. for reportability/trackability. - Reviews cases referred from quality reviewer for reportability/trackability. - Requests and coordinates departmental reviews for cases requiring investigation and possible corrective actions. Follows-up to ensure review is received in a timely manner. Discusses case with Director, Chairpersons as needed to fully address issues identified following review of the case. - Coordinates all activity related to NYPORTS cases. - Participates actively in the discussion of cases in the Departmental PI meeting to ensure issues are identified and addressed. - Assists in preparing physician profile related to reportable cases. - Prepares Risk Management case summary for those cases requiring Root Cause Analysis or in-depth review. - Actively participates in Root Cause Analysis meeting. - Assists Director in obtaining monitoring results for corrective actions instituted in response to Root Cause Analyses that have been conducted by the Risk Management Department. - Keeps abreast of changes in NYPORTS reporting requirements and provide resource assistance to facility staff. Obtain training sessions and seminars as necessary.
7) Preparation of reports: - Preparation of narrative reports for all cases presented to the HHC Board and provide follow-up as - Maintains files for risk management cases and ensure reviews and all reports pertinent to the cases are filed in the case files. - Prepares monthly and quarterly reports as requested by the Director. 8) Assists in the identification of cases that require further evaluation and review. 9) Participates in hospital committees representing risk management as requested. 10) Reviews and tracks all facility occurrence reports, telephone referrals, etc. to provide a comprehensive review that assists in the identification of risk management and quality system deviations and participates in the development of corrective action plans. 11) Root Cause Analysis (RCA) responsibilities: - Responsible for reporting to NYPORTS and/or JCAHO as needed. - Preparation of notification to Executive leadership and HHC Central leadership of reported cases. - Identifies required reviews and members required for Root Cause Analysis meeting. - Assists in the Root Cause Analysis meeting for review of the case. - Prepares Root Cause Analysis for submission to DOH NYPORTS or completion for files and ensures review by Assistant Director and Director of Risk Manager. - Submits RCA within required regulatory framework. - Responds to all DOH requests for further follow-up.
12) At the direction of the Director of Risk Management participates in the facility's response to regulatory agencies (i.e. CMS, DOH, the Justice Center, OPMC), outside counsel and health care agencies, maintaining the integrity of the department and the confidentiality of the employees and patients.
13) Assists Director with DOH On-Site Regulatory Surveys in Response to Patient Complaints, follow-up for RCA, Media events, etc.
14) Assists Director with the review of cases submitted by HIM to determine if they meet Serious Adverse Event categorization.
15) Assists with processing and responding to subpoenas presented to the Risk Management Department.
16) Assists with Mortality reviews and review for Restraint related reporting to CMS as per regulatory guidelines,
17) Assist in review reports for identification of trends and opportunities to improve care.
18) Special projects as assigned by the Director, Risk Management.
Minimum Qualifications
Qualification Requirements : * Qualification for Central Office. # Qualification for Health Care Facility. 1. a. A Baccalaureate Degree in Public Administration, Public Health or Health Care Specialization; and, b. Five* years or four# years of increasingly responsible experience in hospital administration, with particular emphasis on development and evaluation of health care delivery services; or, 2. a. A Master's Degree in Public Administration, Public Health or Health Care Specialization; and, b. Four* years or three# years of increasingly responsible experience in hospital administration, with particular emphasis on development and evaluation of health care delivery services.
Department Preferences
Prior experience in Risk Management, Patient Safety and Quality Management
If you wish to apply for this position, please apply online by clicking the "Apply for Job" button.
NYC Health and Hospitals offers a competitive benefits package that includes:
Comprehensive Health Benefits for employees hired to work 20+ hrs. per week Retirement Savings and Pension Plans Loan Forgiveness Programs for eligible employees Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts College tuition discounts and professional development opportunities Multiple employee discounts programs
At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.
Check us out online:
www.nychealthandhospitals.org
careers.nychhc.org
Docs4nyc.org
Work Shifts
7:00 A.M - 3:30 P.M 8:00 A.M - 4:00 P.M 8:30 A.M - 4:30 P.M 9:00 A.M - 5:00 P.M 10:00 A.M - 6:00 P.M
Job Description
Associate Director, Quality Assurance (Professional Standards Review) - Clinical Investigator/Risk Reduction Specialist
PURPOSE OF POSITION: This position encompasses supervisor, administrative and leadership functions. The responsibilities include both the performance of the functions of the risk management department as well as assisting in the coordination and supervision of the responsibilities and activities of Risk Management at NYC Health + Hospitals/Jacobi.
Unit Specific - CLINICAL/ADMINISTRATIVE:
1) Assists Director and Associate Director of Risk Management in the management, supervision and coordination of activities of the Risk Management Department at JMC.
2) Develops and maintains a collaborative relationship with the medical, nursing and ancillary departments within the institution to promote and to facilitate the principals of risk management and patient safety. Assists the Director and Associate Director in acting as a departmental liaison to the administrative and medical staff when staff request guidance on medical-legal questions and issues with risk management and regulatory implications for the corporation, facility, facility personnel and patients and their families.
3) Maintains a proficiency and working knowledge of applicable 405 regulations, NYC Public Health Law, HHC corporate policies and procedures, DOH regulations, NYPORTS criteria and Hospital policies and procedures.
4) At the direction of the Director utilizes analytical skills and medical knowledge to evaluate the litigation claims received in the department and identify issues with implications for future quality of care and patient safety.
5)Maintains working knowledge of departmental data storage systems and responsible for data entry into the on-line Occurrence reporting system (VOICE) for those cases investigated and reviewed by the Risk Reduction Specialist/Clinical Investigator.
6) Identifies cases that meet NYPORTS criteria, Joint Commission Criteria for Root Cause Analysis or internal review for quality/patient safety purposes. - Reviews cases reviewed by Departments to identify reportable/trackable cases. - Reviews cases referred from staff - verbally, AOD report, occurrence report, mortality review, etc. for reportability/trackability. - Reviews cases referred from quality reviewer for reportability/trackability. - Requests and coordinates departmental reviews for cases requiring investigation and possible corrective actions. Follows-up to ensure review is received in a timely manner. Discusses case with Director, Chairpersons as needed to fully address issues identified following review of the case. - Coordinates all activity related to NYPORTS cases. - Participates actively in the discussion of cases in the Departmental PI meeting to ensure issues are identified and addressed. - Assists in preparing physician profile related to reportable cases. - Prepares Risk Management case summary for those cases requiring Root Cause Analysis or in-depth review. - Actively participates in Root Cause Analysis meeting. - Assists Director in obtaining monitoring results for corrective actions instituted in response to Root Cause Analyses that have been conducted by the Risk Management Department. - Keeps abreast of changes in NYPORTS reporting requirements and provide resource assistance to facility staff. Obtain training sessions and seminars as necessary.
7) Preparation of reports: - Preparation of narrative reports for all cases presented to the HHC Board and provide follow-up as - Maintains files for risk management cases and ensure reviews and all reports pertinent to the cases are filed in the case files. - Prepares monthly and quarterly reports as requested by the Director. 8) Assists in the identification of cases that require further evaluation and review. 9) Participates in hospital committees representing risk management as requested. 10) Reviews and tracks all facility occurrence reports, telephone referrals, etc. to provide a comprehensive review that assists in the identification of risk management and quality system deviations and participates in the development of corrective action plans. 11) Root Cause Analysis (RCA) responsibilities: - Responsible for reporting to NYPORTS and/or JCAHO as needed. - Preparation of notification to Executive leadership and HHC Central leadership of reported cases. - Identifies required reviews and members required for Root Cause Analysis meeting. - Assists in the Root Cause Analysis meeting for review of the case. - Prepares Root Cause Analysis for submission to DOH NYPORTS or completion for files and ensures review by Assistant Director and Director of Risk Manager. - Submits RCA within required regulatory framework. - Responds to all DOH requests for further follow-up.
12) At the direction of the Director of Risk Management participates in the facility's response to regulatory agencies (i.e. CMS, DOH, the Justice Center, OPMC), outside counsel and health care agencies, maintaining the integrity of the department and the confidentiality of the employees and patients.
13) Assists Director with DOH On-Site Regulatory Surveys in Response to Patient Complaints, follow-up for RCA, Media events, etc.
14) Assists Director with the review of cases submitted by HIM to determine if they meet Serious Adverse Event categorization.
15) Assists with processing and responding to subpoenas presented to the Risk Management Department.
16) Assists with Mortality reviews and review for Restraint related reporting to CMS as per regulatory guidelines,
17) Assist in review reports for identification of trends and opportunities to improve care.
18) Special projects as assigned by the Director, Risk Management.
Minimum Qualifications
Qualification Requirements : * Qualification for Central Office. # Qualification for Health Care Facility. 1. a. A Baccalaureate Degree in Public Administration, Public Health or Health Care Specialization; and, b. Five* years or four# years of increasingly responsible experience in hospital administration, with particular emphasis on development and evaluation of health care delivery services; or, 2. a. A Master's Degree in Public Administration, Public Health or Health Care Specialization; and, b. Four* years or three# years of increasingly responsible experience in hospital administration, with particular emphasis on development and evaluation of health care delivery services.
Department Preferences
Prior experience in Risk Management, Patient Safety and Quality Management
If you wish to apply for this position, please apply online by clicking the "Apply for Job" button.
NYC Health and Hospitals offers a competitive benefits package that includes:
Comprehensive Health Benefits for employees hired to work 20+ hrs. per week Retirement Savings and Pension Plans Loan Forgiveness Programs for eligible employees Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts College tuition discounts and professional development opportunities Multiple employee discounts programs