Program Director - Psychiatry Outpatient - MSH - Full Time/Days

The System Behavioral Health Safety and Quality Director is a credentialed individual responsible for overseeing all safety and quality activities in the Behavioral Health Service Line in the Mount Sinai Health System.  Responsible for coordination, standardization, and alignment of all safety and quality policies, procedures and initiatives across the Service Line, including but not limited to clinical policies, incident reporting and review, and performance improvement initiatives. Promotes a a culture of transparency and accountability through the reinforcement of patient safety throughout the Service Line.  Ensures a robust process for compliance with all regulatory requirements and institutional policies and procedures regarding Safety and Quality. Reports to the System Vice President, Behavioral Health, and matrixed reporting to the System Vice President, Quality and Regulatory Affairs and the System Vice President, Risk Management and Patient Safety

General Oversight and Responsibilities:

1. Responsible for direction and oversight of Safety, Quality, Risk Management, and Performance Improvement activities across the Behavioral Health Service Line, including clinical practice effectiveness, quality management, and regulatory compliance.
2. Coordinates the establishment and maintenance of patient care standards which assure the provision of the highest quality of patient care. 
3. Aligns standards, processes and policies of all Safety, Quality, Risk Management and Performance Improvement across the Service Line. 
4. Leads the development and dissemination of Service Line-wide clinical policies and procedures related to regulatory compliance, risk management, and quality management.  Works with campus medical and clinical leadership to ensure that they are operational across the Service Line.
5. Develops and oversees Service Line-wide structure and process of Adverse Event reporting and review, including Serious Adverse Events and any and all events requiring report to Behavioral Health oversight agencies (ie, Justice Center, OMH, OASAS)
6. Collaborates with campus-based Senior Leadership (Chair, Vice Chair) and Quality leadership, along with MSHS Risk Management to 
   1. Oversees, reviews, and monitors investigations, evaluations, and corrective actions;
   2. Oversees reporting to NIMRS (OMH), OASAS, NYPORTS, and the Joint Commission
   3. Oversees and leads the Adverse Event response process across the Service Line, including identification and prioritization of cases for root cause analysis to ensure patient safety
   4. Assures appropriate structure and effective content and process of campus-based departmental reviews of serious adverse events and other reportable events
   5. Co-chairs departmental reviews of select serious adverse and other reportable events
   6. Develops effective, robust, and implementable corrective action plans
   7. Oversees the implementation and spread of corrective actions
7. Develops and creates structures and processes to lead and organize the work of  campus-based Behavioral Health Safety and Quality/Performance Improvement Managers and Specialists and ensures successful completion of campus-based objectives.
8. Develops robust clinical auditing and monitoring system across the Service Line, with feedback and development of improvement efforts.   
9. Develops, executes and manages the Service Line’s performance improvement plan and oversees the development, alignment, review and execution of the performance improvement plans for each campus.
10. Fosters a safety culture throughout the development and implementation of a Service Line-wide integrated patient safety program, ensuring that patient safety concepts are integrated into systems, processes, policies, practices and services. 
11. Promotes staff/clinician/employee/faculty safety through identification and implementation of programs and initiatives to prevent patient-care related injuries/violence.
12. Facilitates programs which recognize excellence in professional practice. 
13. Represents the department on Regulatory, Performance Improvement and Focus Review Committees and assures timely reporting to this committee, extramural agencies (Justice Center, DOH, OMH, OASAS), and development and implementation of any corrective action plans. 
14. Serves as one of the senior Service-Line leadership representatives to extramural agencies regarding matters of safety, quality, risk management and performance improvement (OMH/OASAS/Justice Center/ et al).
15. Assures readiness for all regulatory surveys, and leads management during site visits regarding all QA/PI requirements.
16. Coordinates activities which assure compliance with standards established by the Joint Commission, CMS, NYSDOH, NYS OMH, NYS OASAS, NYS Justice Center, and any other regulator