Director of QM, Hospice & Palliative Care

Responsibilities

• Develops a Quality Assurance/Performance Improvement (QAPI) Plan for Hospice consistent with regulatory requirements, industry standards and patient needs
• Keeps senior leadership abreast of trends within healthcare quality, advises and recommends strategic quality initiatives. Reports on key quality indicators to Senior Leadership
• Collaborates with leadership and hospice staff to develop clinical performance indicators, manage related analysis and benchmarking and disseminate information
• Facilitates data collection and analysis
• Collaborates with clinical and operational departments to ensure implementation of interventions
• Utilizes PDSA methodology and analytical tools to evaluate results
• Oversees the utilization of On-Line Risk Management System (Safetrak) to identify and reduce risks by examining high risk, problem prone processes related to care, treatment or service
• Works collaboratively with the SVP in the development and evaluation of the QI program and evaluation in accordance with the organization’s mission and goals and federal and state regulations
• Works to ensure data reporting needs are met
• Ensures effective analysis of performance metrics in comparison to internal/external benchmarks and goals
• Identifies opportunities for improvement and ensures appropriate interventions are implemented and evaluated
• Collaborate with the Patient Experience team and Customer Experience Department
• Ensures the consistent development, implementation and accountability of performance improvement initiatives to enhance processes that support the provision of high-quality care and ensures effectiveness of performance improvement projects
• Ensures compliance with Federal and NYS regulations by serving as a resource on regulatory matters
• Maintains knowledge of current trends and developments in areas of responsibility through membership in appropriate professional organizations, attend in-services and continuing education to maintain current knowledge and expertise, maintain up to date knowledge of the laws, regulations and payor requirements that affect policy and procedure
• Oversees CMS Hospice Quality Reporting Program (CAHPS and HIS) to ensure compliance with regulatory mandates. Utilizes data to implement Performance Improvement Projects in order to improve practice and service
• Manages performance of direct and indirect reports. Provides orientation, coaching, training and development. Take corrective action when necessary
• Utilizes corporate services resources such as Human Resources, Compliance, Legal, Finance, Information Services, Marketing, etc., as appropriate
• Ensures appropriate staffing and resources to support department/agency services. Monitors productivity throughout the year and participates in annual budget preparation
• Interviews and participates in the selection process for qualified staff in collaboration with Human Resources and department management

Qualifications

• Registered Professional Nurse licensed in New York State
• Bachelor of Science in Nursing required, Master of Science or in progress in nursing or related field preferred
• Minimum 5 years’ experience in Quality Management/Performance Improvement
• Prior experience in hospice
• Application of statistical process control tools
• Knowledge of Federal and NYS DOH Regulations