Director for Quality, Clinical Documentation and Analytics

The Director for Quality, Clinical Documentation and Analytics will report to the EVP and Chief of Hospital Operations and to the Chief Medical Officer with respect to responsibilities pertaining to hospital operations for medical staff and professional matters in accordance with NY State requirements and Medical Staff Bylaws. The Director will provide all administrative and supervisory services required of a Director including, but not limited to, oversight across the hospital on the day to day quality standards of all clinical care units, as well as oversight of unit-based training programs involving quality care, throughput efficiency, and performance improvement such as:

• a) Program development and process improvement implementation;
• b) Oversight of audit and query process;
• c) Regular reporting of performance metrics to senior hospital leadership;
• d) Education and liaising to Service Chiefs, Unit Dyads and Department Chairs;
• e) Review of all high-risk cases for appropriate coding;
• f) Identify opportunities for enhanced documentation to promote improved communication and enhance coding where appropriate.

In addition, the Director will have an established track record of leading quality initiatives related to patient care, clinical documentation and coding, and Value Based Medicine (VBM) focused projects to improve performance as measured by external benchmarks, financial performance, and clinical outcomes. The successful candidate will demonstrate strong communication skills that will lead to effective collaboration across all clinical departments within the hospital and across the health system.

Responsibilities include but are not limited to:

• Working with clinical and coding leadership to maximize the translation of acuity and severity of care into documentation, external benchmarking, and billing. Serving as the key interface between finance, clinical operations, and information technology (MCIT) for projects regarding documentation improvement initiatives.
• Collaborating with Service Chiefs, Unit Dyads, and Department Chairs to ensure timely and accurate documentation by attendings, house staff, and Advance Practice Providers. Serving as a subject matter expert and advisor for clinical, quality, and operational committees.
• Working on quality initiatives, as directed, to improve the measurement and delivery of care as evaluated by external reporting agencies including but not limited to US News World Report, Vizient, CMS, and Leapfrog.
• The Director will also have a specific focus on the following responsibilities:
  • Develop strategies with the hospital leadership that increase the efficiency of operations while improving the quality of patient care and satisfaction in the hospital;
  • Work with teams to develop and implement innovative approaches; using metrics and working with the Chief Medical Officer to improve throughput and reduce Emergency Department holds through strategic changes to rounding processes and patient progression;
  • Facilitate the resolution of variability in executing the value-based standards in the hospital (e.g., documentation, communication, resource utilization, and protocol adherence);
  • Provide overall direction for safety and quality across the hospital, including operationalizing key initiatives (e.g., pain management, sepsis protocols, and HAC avoidance);
  • Ensure high quality value-based services for all patients cared for by the hospital's staff and to assess continuously and improve ongoing quality assurance and improvement programs;
  • Monitor in real time and actively engage in the achievement of hospital center, departmental, unit-based, as well as publicly reported metrics (e.g., timely discharge, infection rates, length of stay HAHPS, and 30-day readmissions);
  • Optimize the hospital's clinical documentation strategy including but not limited to the following areas of focus:
    • Review of risk factor documentation on mortality cases;
    • Review of risk factor documentation on Hospital-Acquired Condition (HAC) cases;
    • Review of risk factor documentation on long stay cases;
    • Review of al AHRQ PSI's with guidance provided to clinicians reviewing for documentation,
    • Review of provider templates for best Clinical Documentation Improvement (CDI) capture;
    • Strategic alignment with CDI on chart review process;
    • H&P, Discharge Narrative, and Progress Note table audits;
    • Enhancement of provider billing practices;
    • Implementation of AI and NLP-based strategies for improving documentation;
• Proactively identify and communicate trends and…