Department Information

Description of Job

Job Duties include but are not limited to:

• 
  Reviews hospital incidents as they occur. Determines which of these meet criteria for reporting to the Colorado Department of Public Health and Environment (CDPHE) and reports those that do. Reporting to CDPHE is governed by strict time parameters. Reporting requires extensive knowledge of hospital policy and procedure and how it is applied in the clinical milieu. This involves formulating a detailed report that meets the expectations of CDPHE about how patients are being kept safe in the wake of an incident, the history of the patient and review of their current plan of care, what corrective/disciplinary action was taken with staff if they were involved in an incident, and quality improvement efforts that emanate from the incident.
• Maintains and monitors incident data related to quality measures and provides monthly data to the Quality Council on incident trends and ongoing performance improvement projects.
• Coordinates and oversees the Tracer process, which mimics the Tracer methodology employed by the Joint Commission when they conduct on-site surveys for themselves and CMS. This involves intense observation of an area including environment of care, patient-staff interactions, observing medication administration, seclusion and restraint, program, plan of care reviews, etc.
• Initiates, monitors, and tracks performance improvement projects based on incident trends and areas identified for improvement utilizing the Plan, Do, Study, Act or Lean models
• Assists in the implementation of the Quality Management process that leads to positive and measurable impacts of CMHIFL’s strategic Quality Assurance and Performance Improvement Plan.
• Audits all documentation related to seclusion and restraint. Assesses trends and tracks data for ongoing quality review. Requires extensive knowledge of the Seclusion and Restraint Policy as well as tenets of Verbal Judo, Recovery and Trauma-Informed care when ascertaining appropriate use of seclusion and restraint as a treatment intervention. Decides if documentation adequately reflects the necessary danger to self or others as State of Colorado Position Description 07/2022 justification for use of this intervention. Follows up with supervisors and/or staff responsible for documentation to ensure that any errors or missing information is corrected.
• Monitors and tracks National Patient Safety goals; leads Lean and rapid improvement events, consults with and assists clinical teams and departments in measuring, analyzing, and improving the quality and safety of treatment; establish and conduct interdepartmental hospital Performance Improvement workgroups to address and monitor clinical goals and quality initiatives.
• Assists other disciplines with writing and revising hospital policies and serves as a quality management representative on policy-writing workgroups and committees. Ensures hospital policies align with regulatory standards.
• Work with hospital management and staff to determine the level of compliance with regulatory standards and rules and develops plans for compliance. Monitor various publications, websites, and other media for current standard changes and issues

Minimum Qualifications, Substitutions, Conditions of Employment & Appeal Rights

Note: Please be sure to indicate related experience in each job experience listed, as these will determine calculations of related experience.

Substitution:
Additional appropriate clinical experience will substitute for the degree requirement on a year-for- year basis and combined with the required two years professional work experience will total six years related work experience.
- - OR - -
Additional appropriate education will substitute for the experience requirement on a year-for- year basis.

Required Competencies:

• Ability to work independently
• Excellent interpersonal skills with the ability to think critically
• Excellent verbal and written communication skills
• Strong organizing, planning and prioritizing skills
• Ability to keep sensitive information confidential

Preferred Qualifications:

• Experience working in a clinical/behavioral health environment
• Experience with CDPHE Occurrence Reporting Requirements and Statutes
• Experience with event reporting and investigation as it relates to care delivery in the inpatient psychiatric setting.
• Computer skills, and experience working with/in Google or navigating an electronic health record is a plus.
• Experience writing professional reports
• Knowledge of Quality Assurance and Performance Improvement

Conditions of Employment:

• Full Background: CDHS employees (all Direct contact with vulnerable persons): CBI name check and fingerprint check, ICON Colorado court database, Medicare fraud database, Reference Checks, Professional License verification (licensure requirements), Drug Screen, PREA (Division of Youth Services), Trails check (direct contact with children), CAPS (direct contact with adults – Mental Health Institutes, Regional Centers, Veterans Community Living Centers).
• A Tuberculosis Test (TB) will be required upon hire
• May work weekends or alternate shifts/schedules
• Travel- Position must travel to remote work sites and must utilize a state vehicle, if available.
  If not, must utilize personal vehicle and submit for mileage reimbursement.
• Must demonstrate the ability to lift 50 pounds, bend, squat, etc. and perform behavioral interventions proficiently (training and continuously throughout employment).
• Former State employees who were disciplinarily terminated or resigned in lieu of termination must disclose the information on the application and provide an explanation why the prior termination or resignation should not disqualify the applicant from the current position. Absent extraordinary circumstances, prior disciplinary termination or resignation in lieu of termination will disqualify the applicant from future State employment with CDHS.
• On or after October 31, 2021, each facility shall ensure all newly hired employees or support staff members are fully vaccinated at the time of hire or receive their first dose of a two-dose protocol, or a single-dose vaccination, prior to providing any care, treatment, or other services for the facility and/or its clients. Upon hire, new employees will have three (3) business days to provide attestation to their status with proof of vaccination. Vaccinated employees must provide proof of first dose prior to providing care.
• Note: Fully Vaccinated means two (2) weeks after a second dose in a two-dose series of the COVID-19 vaccine, such as the Pfizer, Moderna or Novavax vaccine, or two (2) weeks after the single-dose vaccine, such as Johnson & Johnson’s Janssen vaccine.
• Religious and medical exemptions and reasonable accommodation shall be addressed as required by law pursuant to the Equal Employment Opportunity Commission’s vaccination guidance. If you would like to request a medical or religious exemption, please contact CDHS_HumanResources@state.co.us
  
  Appeal Rights:
  
  If you receive notice that you have been eliminated from consideration for this position, you may file an appeal with the State Personnel Board or request a review by the State Personnel Director.
  
  An appeal or review must be submitted on the official appeal form, signed by you or your representative. This form must be delivered to the State Personnel Board by email (dpa_state.personnelboard@state.co.us), postmarked in US Mail or hand delivered (1525 Sherman Street, 4th Floor, Denver CO 80203), or faxed (303.866.5038) within ten (10) calendar days from your receipt of notice or acknowledgement of the department’s action.
  
  For more information about the appeals process, the official appeal form, and how to deliver it to the State Personnel Board; go to spb.colorado.gov; contact the State Personnel Board for assistance at (303) 866-3300; or refer to 4 Colorado Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, at spb.colorado.gov under Rules.

Supplemental Information

How to Apply

• Strong, secure, yet flexible retirement benefits including a PERA Defined Benefit Plan or PERA Defined Contribution Plan www.copera.org plus 401(k) and 457 plans
• Medical and dental health plans
• Employer supplemented Health Savings Account
• Paid life insurance
• Short- and long-term disability coverage
• 11 paid holidays per year plus vacation and sick leave
• BenefitHub state employee discount program
• Employee Wellness program MotivateMe
• Excellent work-life programs, such as flexible schedules, training and more

• Remote work arrangements for eligible positions

• 
  Some positions may qualify for the Public Service Loan Forgiveness Program. For more

We believe in a people-first approach: To serve the people of Colorado, we develop a culture and work environment that creates an energized, inspired, and healthy team capable of giving their best to Coloradans.

Balance creates quality of life: We want our team to be resilient through a supportive workplace that values flexibility, health and wellness, and employee engagement.

We hold ourselves accountable: We take responsibility through our actions, programs, and results for the state of health and human services in Colorado.

Transparency matters: We are open and honest with employees, our partners, the Coloradans we serve, and the public.

We are ethical: We abide by what is best for those we serve by doing what is right, not what is easy.

Collaboration helps us rise together: We work together with all partners, employees, and clients to achieve the best outcomes for Coloradans.

We are committed to increasing the diversity of our staff and providing culturally responsive programs and services. Therefore, we encourage responses from people of diverse backgrounds and abilities.

ADAA Accommodations: CDHS is committed to the full inclusion of all qualified individuals. As part of this commitment, our agency will assist individuals who have a disability with any reasonable accommodation requests related to employment, including completing the application process, interviewing, completing any pre-employment testing, participating in the employee selection process, and/or to perform essential job functions where the requested accommodation does not impose an undue hardship. If you have a disability and require reasonable accommodation to ensure you have a positive experience applying or interviewing for this position, please direct your inquiries to our ADAA Coordinator, Nancy Schmelzer, at cdhs_ada@state.co.us or call 1-800-929-0791.

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