**Job Description** 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 **Qualifications** Master’s or higher education required in Nursing, Social Work, or other relevant discipline within professions in Behavioral Health Minimum of 5 years of progressive clinical management experience within clinical behavioral health services. Strong preference for experience in inpatient/emergency behavioral health services management. Must have experience in management and oversight of behavioral health-related quality assurance and performance improvement activities. Name: Current NYS licensure (Nursing, Psychology, Social Work, P.A. or related profession) Certification in Risk Management and/or Patient Safety strongly preferred. **Compensation Statement** The Mount Sinai Health System (MSHS) provides a salary range to comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for this role is $132,400.32 - $209,622.00 Annually. Actual salaries depend on a variety of factors, including experience, education, and hospital need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits. Non-Bargaining Unit, 388 - Psych Opd - MSH, Mount Sinai Hospital **Responsibilities** **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 regulatory agencies. 17. Monitors and ensures compliance with all relevant city, state and federal laws, government regulations, accrediting agency standards, and Health System policies. 18. Develops and implements strategies for long range goals, annual objectives, and strategies to determine best practices for safety, quality, and performance improvement for the Service Line **Data Collection and Monitoring:** 1. Tracks, analyzes, aggregates and trends events, near misses, and other incidents to identify, address and report on Service-Line wide and campus-based patterns 2. Oversees the collection of data, report preparation, and statistical analyses so that requested data is reported and analyzed in an appropriate manner. 3. Analyzes data to identify areas of improvement and to develop programs/initiatives to address gaps. 4. Develops and manages effective quality reporting mechanisms for internal and external use. 5. Analyzes campus-specific and Service-Line performance on publicly reported quality measures (ie, IPFQR, OMH and OASAS-specific quality measures), and works with campus leadership to continuously improve performance. 6. Oversees development and implementation of Service-Line wide training initiatives and continuing education related to performance improvement/corrective action. 7. Provides strategic leadership in assessing, developing and implementing quality data systems and analytic tools. 8. Anticipates national trends an initiatives in performance improvement, clinical quality, healthcare informatics, and the use of clinical technology to improve the quality and effectiveness of clinical care **Organizational/Managerial:** 1. Provides senior level supervision and oversight to members of the System Behavioral Health Safety and Quality Team in all aspects of performance. 2. Works effectively within matrixed reporting environment to campus-specific department leadership and safety/risk leadership, as well as with System-based counterparts. 3. Completes annual Performance Appraisals for Safety and Quality team, and mentors and guides campus-based Behavioral Health Safety and Quality staff. **Communication/Relationships:** 1. Work collaboratively with Health System and campus leadership, medical staff, nursing staff, and all clinical staff to accomplish goals 2. Serve as a Service Line and System-wide internal resource regarding Behavioral Health quality, performance improvement, and regulatory affairs 3. Confers with and advises System Administration, Human Resources, Corporate Compliance and Legal Affairs based on clinical expertise and experience. 4. Fosters an environment that supports transparency and fairness, in which staff members feel safe to report errors and participate in the analysis and mitigation of them. 5. Maintains strict confidentiality in all matters. 6. Demonstrates a professional, courteous, and respectful attitude in dealing with patients, families, and significant others. 7. Displays courtesy, tact, patience during interactions with all members of the hospital staff and extended community. **Professional Development:** 1. Maintains professional affiliations and enhances professional development to keep pace with healthcare trends. 2. Participates in the development of other staff members 3. Meets regulatory, licensure and annual health assessment requirements 4. Identifies learning strengths and needs All other responsibilities as assigned. **About Us** **Strength Through Diversity** The Mount Sinai Health System believes that diversity, equity, and inclusion are key drivers for excellence. We share a common devotion to delivering exceptional patient care. When you join us, you become a part of Mount Sinai’s unrivaled record of achievement, education, and advancement as we revolutionize medicine together. We invite you to participate actively as a part of the Mount Sinai Health System team by: + Using a lens of equity in all aspects of patient care delivery, education, and research to promote policies and practices to allow opportunities for all to thrive and reach their potential. + Serving as a role model confronting racist, sexist, or other inappropriate actions by speaking up, challenging exclusionary organizational practices, and standing side-by-side in support of colleagues who experience discrimination. + Inspiring and fostering an environment of anti-racist behaviors among and between departments and co-workers. At Mount Sinai, our leaders strive to learn, empower others, and embrace change to further advance equity and improve the well-being of staff, patients, and the organization. We expect our leaders to embrace anti-racism, create a collaborative and respectful environment, and constructively disrupt the status quo to improve the system and enhance care for our patients. We work hard to create an inclusive, welcoming and nurturing work environment where all feel they are valued, belong and are able to advance professionally. Explore more about this opportunity and how you can help us write a new chapter in our history! **“About the Mount Sinai Health System:** Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 43,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time — discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients’ medical and emotional needs at the center of all treatment. The Health System includes approximately 7,400 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. We are consistently ranked by U.S. News & World Report's Best Hospitals, receiving high "Honor Roll" status, and are highly ranked: No. 1 in Geriatrics and top 20 in Cardiology/Heart Surgery, Diabetes/Endocrinology, Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics, Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U.S. News & World Report’s “Best Children’s Hospitals” ranks Mount Sinai Kravis Children's Hospital among the country’s best in several pediatric specialties. The Icahn School of Medicine at Mount Sinai is ranked No. 14 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges. Newsweek’s “The World’s Best Smart Hospitals” ranks The Mount Sinai Hospital as No. 1 in New York and in the top five globally, and Mount Sinai Morningside in the top 20 globally. The Mount Sinai Health System is an equal opportunity employer. We comply with applicable Federal civil rights laws and does not discriminate, exclude, or treat people differently on the basis of race, color, national origin, age, religion, disability, sex, sexual orientation, gender identity, or gender expression. We are passionately committed to addressing racism and its effects on our faculty, staff, students, trainees, patients, visitors, and the communities we serve. Our goal is for Mount Sinai to become an anti-racist health care and learning institution that intentionally addresses structural racism.” **EOE Minorities/Women/Disabled/Veterans** **Compensation Statement** Mount Sinai Health System (MSHS) provides a salary range to comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $132400.32 - $209622 Annually. Actual salaries depend on a variety of factors, including experience, education, and hospital need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.