The Manager, Quality Assessment and Performance Improvement, promotes standards and healthcare practices that comply with the standards and conditions of participation as they are set by the state agencies in which they operate, CMS and Joint Commission. This position is responsible for the oversight of facility-level QAPI function and provides leadership to QAPI personnel at each facility. This individual is responsible for implementation and oversight of the QAPI program which ensures the safety, integrity and security of the individuals served.Essential Functions:
Education and Experience Requirements:
- Works with Corporate Director of Quality implementing organization-wide quality programs at the hospital level. Primary responsibility is to provide support and oversight for facility quality directors.
- Supervises all activities relative to data gathering, input and review of data collection measures and adherence to preset goals.
- Provides audit and feedback around quality data abstracting, ensuring that when indicated, corrective actions plans are developed and implemented for any areas of deficit identified.
- Works collaboratively with Corporate Director of Quality to ensure that areas identified are corrected. Communicates findings to Corporate Director of Quality and Operational leadership according to a predetermined method.
- Coordinates training and education for QAPI principles and regulatory standards as indicated.
- Serves a resource for the facility Quality Directors as it relates to QAPI policies and processes.
- Collaborates with Corporate Director of Quality in reviewing and developing appropriate forms and policies as needed.
- Maintains compliance with all Company policies and procedures. Strict adherence to Company Code of Conduct. Always maintains confidentiality of all facility and resident information, as observed by peers and management.
- Attends all mandatory education programs and can describe his/her responsibilities related to general safety and regulatory compliance.
- Completes other assigned duties under the direction of the Corporate Director of Quality.
Bachelor’s degree required. Experience in healthcare field preferred. Experience in performing healthcare audits and monitoring functions preferred. Experience in inpatient quality assessment and management. Multi-site management preferred. Experience in data compilation, data analytics. Behavioral health experience in these areas preferred.Qualifications/Skills:
- CPHQ certification preferred.
- Demonstrates strong computer skills to navigate MS office products and electronic quality software solutions.
- Knowledge and understanding of CMS, The Joint Commission and State Department of Health and Hospitals regulations.
- Excellent written and oral communication skills.
- Demonstrates personal traits of a high level of integrity, team orientation, professionalism, and trustworthiness. Places a high value on ethical standards and treating others with dignity and respect.
Subject to many interruptions. Occasional pressure due to multiple calls and inquiries. This position can be high paced and stressful; must be able to cope mentally and physically to atmosphere. This person might sometimes experience disagreeable odors, sights and/or unpredictable patient behavior. Work requires spending approximately 90% or more of the time inside a building that offers protection from weather conditions but not necessarily from temperature changes.