As a member of the organization's management team, the Director, Performance Improvement and Compliance supports CHAP's mission, vision, and goals to ensure CHAP is the preferred accreditor of home and community-based care providers.
Serves as a resource person to CHAP for Performance Improvement and Quality Management, including sustaining the validity and rigor of accreditation decisions
Supports required education and training related to Performance Improvement
Oversight of compliance with CMS as well as state regulations
Manage, monitor, and report performance improvement activities
Oversees and manages changes to organizational policies and procedures and the implementation of Standard Operating Procedures
Works with the Senior Leadership Team to identify, focus, and support improvement efforts
Works with the CEO and CNO to organize and lead Committees and Teams designed to facilitate accreditation activities
Participates in cross-department process improvement teams and activities
May perform site visit audits
Gather, analyze, and present performance data to identify opportunities for improvements related to key objectives.
CPHQ or equivalent required
Demonstrated ability to interface with clinicians in a process improvement environment
Ability to organize, analyze, and interpret quantitative and qualitative data to monitor trends in performance and inform organizational decision making
Ability to work under pressure, strong organizational and analytical skills is required.
Experience in managing teams
Demonstrated project management skills with the ability to handle multiple concurrent projects.
Ability to work effectively with providers and teams across departmental lines, as well as externally interface with national organizations representing quality in healthcare
Excellent written and verbal communication skills
Proficiency in MS Word, PowerPoint, Excel
This position involves full time work based in the Washington, DC office.
Due to the nature of this job, lifting of materials and equipment of up to 10 pounds is required.
Extended periods of sitting/standing are required.
Some local and national travel may be required.
English fluency is required, as are excellent writing skills.
The successful candidate must be able to hear, see and comprehend written documents to effectively perform this job.
Extensive work on a PC and telephone, at a desk, is required.
The physical demands and work environment that have been described is representative of those an employee encounters while performing the essential functions of this position.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.
Education, Training and Experience
Three to five years of experience in developing, implementing, and evaluating QI/PI initiatives in an accredited healthcare organization.
Previous regulatory experience preferred
Three (3) to five (5) years of professional clinical experience, RN preferred but not required.
The Community Health Accreditation Program, Inc. (CHAP) is an independent, non-profit accrediting body. It was the first accrediting body for community-based health care organizations in the United States and was created in 1965 as a joint venture between the American Public Health Association (APHA) and the National League for Nursing (NLN). These organizations brought to fruition the futuristi...c view that accreditation was the needed mechanism for recognizing excellence in community health practice. In 1988, CHAP became a separately incorporated, non-profit subsidiary of the NLN under the CHAP name. In 2001, it was spun-off by the NLN and became an independent, non-profit corporation.
Because CHAP was granted "deeming authority" from the Centers for Medicare and Medicaid Services (CMS) for home health in 1992 and hospice in 1999, CHAP now has the regulatory authorization to survey agencies providing these services to determine whether they meet the Medicare Conditions of Participation (COPs). This marks a change from the previously used state surveys. In 2006, CMS granted CHAP full deeming authority for Home Medical Equipment (HME).