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 high-quality 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 on-call coverage with 24/7 BMCHS behavioral health support.

Responsible for the day-to-day 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., follow-up 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 follow-up 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 well-being, and organizational integrity.
• Develop and implement risk management policies, procedures, and training programs.
• Oversee incident reporting, investigation, and resolution processes, ensuring timely and effective follow-up.
• Serve as the system’s primary liaison with legal counsel and insurance providers regarding risk-related 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 follow-up 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 risk-prone 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 system’s 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 facility-specific 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 evidence-based interventions.
• Organizes and leads Kaizen activities, as needed, Kaizen, or continuous improvement, is a business philosophy that involves employees at all levels of a company to make regular, incremental improvements to processes. The 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 self-motivated. 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 on-call purposes.
• Demonstrates flexibility and adaptability as role may evolve e in a changing environment.

Equal Opportunity Employer/Disabled/Veterans