Health Professional III- Occurrence Reporter CMHHIP

About Position

This position assists with the implementation of the CMHHIP Critical Incident Reporting Program as outlined in CRS 25-3-109. This position reviews and analyzes incident reports, using the standards of practice set by the Colorado Department of Public Health and Environment (CDPHE), and provides follow up for Colorado Mental Health Institute at Pueblo (CMHHIP), Office of Behavioral Health (OBH), and Colorado Department of Human Services (CDHS).

Additionally this position investigates and determines which events constitute a critical incident/occurrence and determines which of those must be reported to Executive Management in Denver, CMHHIP leadership, including the hospital CEO and the Deputy Director of Clinical Services for OBH and CDPHE. Additional duties include the following:

• Ongoing development and implementation of the CMHHIP Critical Incident Reporting Program as outlined in CRS 25-3-109.
• Collects, analyzes and reports data related to hospital-wide incidents in order to improve patient and staff safety.
• Investigates and determines which events constitute an occurrence that must be reported through the iNotify database to Executive Management in Denver, CMHHIP/OBH leadership, including the hospital CEO and the Deputy Director of Clinical Services for OBH. Conducts mini root cause analyses to determine which incidents rise to reporting to CDPHE or the Joint Commission (TJC) as a Sentinel Event.
• Investigates and develops follow-up reports on any occurrence that meets criteria, including, but not limited to, visual review of video footage, staff/patient interviews, recording interviews, reviewing documentation, and entering patient care areas.
• Involves completion of Apparent Cause Analysis and Root Cause Analysis for critical incidents investigations.
• Completes emergency physical intervention/restraint training (CTI) and CPR. Advises program and unit leadership, Department of Public Safety and Department Heads on serious allegations requiring action by an appointing authority to maintain patient safety.
• Formulates recommendations for changes or improvements in operating procedures.

• Completes audits under the direction and in collaboration with the Quality Management QAPI team.
• Collects and summarizes findings by aggregating data per regulatory guidelines.
• Reports findings to the Director of Quality Management, and QAPI Supervisor.
• Assists with data input and system maintenance for Quality Management spreadsheets and databases for audits, focused audits, or focused audits requested by legitimate special interest entities affiliated with CMHHIP and TJC Tracers.
• Assists in determining the best method of data presentation based on the intended audience.
• Uses an established database to maintain results of all audits and generate comprehensive reports (including graphs and charts) for the Director of Quality Management, Executive Committee or Program and Department Heads.
• Maintains a system for tracking chart delinquencies with a goal of no delinquencies older than 30 days hospital-wide.
• Monitors delinquencies and works with clinical staff to correct them within established timelines.
• Coordinates resolution of delinquencies with Quality Management QAPI team.
• Provides reports on delinquencies to the Director of Quality Management and Quality Management QAPI supervisor.
• As part of the utilization management program, may participate in various aspects of utilization review, including composing clinical letters in reply to third-party payer denial and auditing the medical record for documentation to support medical necessity.

• Provides back-up support in the Tracer process, mimicking the tracer methodology used by the Joint Commission during on-site surveys.
• Uses knowledge of Joint Commission and CMS Standards to perform intense observation of patient care areas, environment of care, patient-staff interactions, medication administration, seclusion/restraint, programming, and plan of care reviews; conducts detailed medical record audits on units visited to ascertain compliance with standards.
• Tracers review Ambulatory Care Services,…