DIRECTOR OF QUALITY ASSURANCE

Job Summary: Develops and implements an agency-wide Quality Assessment and Performance Improvement (QAPI) Program focusing on assessment and improvement in clinical care and supporting processes, and compliance with state and federal regulations. As a member of the clinical management team, serves as an agency expert and resource for the electronic clinical information system; utilizes agency technology resources to drive performance improvement. Provides leadership and oversight for the QAPI program via data collection, analysis, reporting, and benchmarking. Serves as agency Compliance Officer.

Qualifications:

• Graduate of an accredited school of nursing, BSN/master's degree preferred. Current Texas RN license.
• Minimum of two (2) years experience in nursing and four (4) years experience in home health care or hospice preferred. Compliance certification preferred.
• Knowledge of applicable federal, state, and accreditation (CHAP) regulations and of Performance Improvement principles preferred; willingness to learn and remain current required.
• Excellent written/verbal communication skills.
• Ability to facilitate and support change.
• Ability to identify staff education and training needs from audit and quality data, and to plan and deliver effective in-services.
• Has prior work experience with demonstrated competency in job duties.
• Evidences personal integrity, appropriate personal presence, and strong work ethic.
• Communicates effectively, both verbal and written.
• Able to solve problems, make decisions, set priorities, and keep accurate, orderly records.
• Able to work effectively within a team approach as well as independently.
• Able to work flexible hours as needed.
• Computer and software competence required.

Duties and Responsibilities:

Performance Improvement

• Coordinates all aspects of the Quality Assessment/Performance Improvement (QAPI) Program and other review processes to ensure quality patient care.
• Participates in the monitoring and data collection of QAPI activities and other review processes as needed.
• Prepares and submits reports of QAPI activity; chairs and coordinates the QAPI committee. Maintains QAPI files, records, resources, and activity reports.
• Oversees CHAP accreditation preparation, self-study reports, and actual survey experiences.
• Oversees the process of developing, reviewing, educating, and maintaining policies and procedures.
• Implements special programs to promote compliance and excellence.
• Promotes practices that ensure full compliance with policies and procedures and CHAP standards.
• Meets goals and objectives set out in the annual business plan.
• Educates clinical leadership and staff to promote active involvement and effectiveness in quality assessment and performance improvement.
• Identifies educational opportunities and training needs for all staff based on trends found through QAPI data, chart audits, and survey readiness activities, and ensures agency-wide staff education is delivered on these topics at least quarterly.
• Facilitates a regular debrief with clinical leadership to discuss ongoing chart audit findings, trends, and concerns, and to track follow-up and corrective action to resolution.

Compliance/Regulatory Oversight

• Oversees policies and procedures to assure that systems for compliance are in place, in cooperation with the administrative team.
• Assists with the implementation and preparation of processes and systems necessary to achieve successful state surveys and accreditation.
• Reports to the CEO any discrepancies in processes and systems that might present a compliance or regulatory obstacle, suggests process improvement remedies, and coordinates improvement team effort.
• Acts as the agency Compliance and Privacy Officer in monitoring compliance with state, federal, and CHAP program guidelines.
• Assists in interpretation of state law, federal regulations, and accreditation program guidelines to facilitate optimal and compliant agency operations.
• Reviews all incidents, concerns, and grievances to ensure appropriate follow-up and documentation have occurred.
• Ensures timely submission of Additional Documentation Requests (ADRs) and other record requests from outside entities (e.g., MACs, RACs, ZPICs/UPICs, and other auditing or payer bodies), and maintains a tracking log of all requests, due dates, and submission status.

Medical Records

• Oversees the Medical Records Department's processes and procedures.
• Guides the concurrent and retrospective review of medical records to assure quality patient care is reflected in documentation and that improvement processes are appropriately focused and effective.
• Compiles and analyzes recurring audit findings from medical record reviews to identify trends, and brings these to clinical leadership through the quarterly education and debrief process.

Face to Face

• Provides oversight of the Face to Face process in compliance with regulatory requirements.
• Supervises staff coordinating Face to Face visits.

Clinical Documentation

• Acts as a consultant, change agent, and teacher in the areas of clinical documentation, the electronic clinical information system, and compliance with accreditation and regulatory requirements.
• Serves as Subject Matter Expert for the electronic clinical information system.
• Leads the process of implementation for strategic initiatives related to clinical documentation and process improvement.
• Leads training and orientation activities related to clinical documentation.
• Develops expertise in the agency's electronic medical record system.
• Assists with the development of lesson plans for clinical computer training.
• Trains new and current employees on the agency's electronic clinical information system (FireNote).

Clinical Practice and Special Projects

• Coordinates special projects as assigned that impact agency program development and address areas identified as needing improvement.

Emergency Disaster Coordinator

• Demonstrates in-depth knowledge of, interprets, and ensures compliance with all local, state, and federal regulations relating to the operations of the Agency and emergency preparedness and response, in order to implement comprehensive policies and procedures.
• Assists in fostering awareness of the importance of emergency preparedness and developing an organizational culture committed to it by providing leadership in complying with regulations.
• Serves as the designated contact person for the Agency regarding emergency preparedness. Acts as the agency liaison to federal, state, tribal, regional, and local emergency preparedness officials, emergency medical services, and local community support systems in a disaster, keeping a list of emergency contacts.
• Develops systems and processes for ensuring the Agency's ability to provide care to patients and families throughout an emergency.
• Ensures that the Agency's daily operations and actual practice conform to requirements as defined in the Agency's policies and procedures and applicable Texas Health and Human Services Commission (HHSC) regulations and Centers for Medicare and Medicaid Services (CMS) requirements.
• Develops and conducts training on emergency preparedness and response, and ensures that all Agency employees, volunteers, and contracted staff receive adequate and appropriate training.
• Conducts drills and exercises, twice per year, to test the emergency plan and monitor and evaluate responses. Revises policies and procedures as appropriate.
• Ensures that the Agency maintains a current list of patients prioritized by care needs.
• Responsible for the monitoring of public information systems for disaster-related news 24/7, and informing the Agency as soon as possible.
• Documents all aspects of a disaster as part of the Recovery Phase for further inspection/review. Develops a disaster recovery plan following a disaster.
• Other duties as assigned by the Administrator.

General

• Supports the philosophy and objectives of Hope Hospice.
• Maintains professional competency in area of expertise.
• Maintains professional licensure and/or certification current; knows and abides by professional practice rules.
• Stays current with governmental and accreditation requirements affecting area of responsibility.
• Maintains professional appearance, behavior, attitude, and integrity.
• Keeps abreast of and abides by policies and procedures of the agency.
• Maintains confidentiality and ethical behavior.
• Promotes a team approach through cooperation, mutual respect, flexibility, and dependability.
• Participates in appropriate meetings and activities, including Performance Improvement.
• Exhibits good stewardship of resources, including self-care.
• Reads materials and attends in-services, seminars, or conventions as needed for professional growth.
• Contributes to an atmosphere of excellence, mutual respect, and caring.
• Performs other duties as assigned.

Working Conditions: Normal office environment; moderate amount of standing, walking, stooping, sitting, reaching; minimum amount of lifting required. May occasionally drive to and visit patient homes and nursing homes, which may include climbing stairs and variable circumstances.

Please note this job description has been designated to include the general nature and level of work performed by employees in this position. It is not designed to contact or to be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of the employee assigned to this job. Duties, responsibilities, and activities may change at any time with or without notice.