The Director of Quality is responsible for the overall agency wide continuous quality improvement program that is both patient and organization focused to ensure quality benchmarks are met or exceeded across the organization. This individual performs patient chart reviews, addresses deficiencies in direct and indirect quality care and activities and collaborates with the Executive Director, Chief Medical Officer, Department Leaders and hospice team to educate and implement change across the spectrum to provide quality patient care in the community. Assists with ensuring compliance with all applicable Federal, State and local laws, rules and regulations, as well as CHAP Standards of Excellence, as they apply to the organization. Designs a quality strategic plan that includes annual goals and focused assessments using data from multiple resources. Leads all of the performance improvement teams, teaching analytic tools to support assessment and plans.
Reports to the Chief Medical Officer
Job Duties and Responsibilities:
Specific to Job Position:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
* Maintains up to date knowledge of Federal and State hospice rules and regulations, LCD Guidelines, CHAP Standards of Excellence, Nevada Medicaid rules and regulations and CMS Conditions of Participation. * Develops and implements systems and policies as well as procedures for analysis of performance measurement data. * Develop, research, train and implement Emergency Preparedness Program for all agencies within ProCare Hospice of Nevada. * Responsible for collecting and analyzing data to identify trends, working with the Quality Department and clinical teams on root cause analysis. * Directs all activities pertaining to quality monitoring. * Directly supervises and manages employees in the Quality Department. * Collaboratively creates action plans for improvement including follow up evaluation of data and organizational performance in meeting or exceeding quality benchmarks to ensure consistent improvement. * Coordinates and oversees completion of annual agency-wide systematic review and annual policy review. * Plans and oversees the Quality Assurance and Quality Assessment Performance Improvement committee meetings. * Responsible for coordinating, reporting and distribution of all satisfaction surveys (CAHPS, etc.) for the Hospice program ensuring improvement agenda based on trends. * Responsible for gathering data from unusual occurrences and complaints and summarizing trending at designated timeframes for reporting in line with regulatory requirements. * Collaborates educational opportunities and activities for the development of quality and regulatory educational programs. * Acts as HIPAA Security Officer for the agency. * HIS Agency Officer; takes responsibility for accurate and timely HIS submissions * Demonstrates high-level understanding of Electronic Medical Record system; is a super user of the system and collaborates with IT and others in the Quality Department to ensure appropriate use of, and training in, the EMR system and other technologies utilized by the company. * Completes quarterly state reports. * Monitors and reports to the Executive Director/Governing Board those processes impacting hospice’s vulnerability to fraud, abuse, and waste, and recommends problem solving techniques. * Develop, lead, facilitate and advise internal committees such as quality improvement, quality assurance, patient safety and risk management. * Collaborates with department managers to suggest potential praise or disciplinary action for quality-related employee performance. * Works closely with the Governing Body, Chief Medical Officer and Director of Nursing to ensure safe agency practices as well as legal and ethical practices all within the regulatory guidelines for both state and federal standards. * Investigates and acts on matters related to agency compliance with all hospice employees/volunteers, contracted employees and vendors. * Presents performance data findings monthly to the management team and the Governing Board. * Duties and responsibilities may be added, deleted, or changed at any time at the discretion of the Governing Board and/ or Executive Director, formally or informally, either verbally or in writing.
* Demonstrates ability to problem-solve and make decisions by: Assessing situations and considering all possibilities to resolve the issues, then correcting the problems presented in a reasonable amount of time. * Seeks guidance and direction as necessary, utilizing proper chain of command. * Demonstrates knowledge and respect of rights and responsibilities by observance of patient/participant: Privacy, confidentiality and safety, including reporting of patient/participant abuse or neglect. * Demonstrates professionalism at all times by respectful interpersonal relationships with: Team members, patients/participants and families, supervisors, community members. * Demonstrates knowledge of compliance with all agency policies and procedures. * Demonstrates effective time management skills by: Coordinating activities to achieve maximum productivity and efficiency, willingness to adjust or revise work schedules as requested, completing assigned projects within specified time frames. * Assumes responsibility for on-going personal development and continuing education. * Stays current with all mandatory agency requirements.
1. Participates appropriately in emergency procedures (including disaster drills).
2. Operation of equipment in a safe manner and shares responsibility for communicating safety violations or
unsafe practices to management.
3. Equipment Used: General office equipment (telephone, copy machine, fax machine) and motor vehicles.
4. Category 2 for potential exposure to blood/body fluids. (Does not usually require the performance of procedures or other tasks in the work routine that involve exposure to blood, body fluids or tissues, but Category 2 tasks may require the unexpected performance of these procedures).
5. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
6. Utilizes appropriate PPE as needed.
7. Follow the designated plan of action in the event of a fire or other emergency/disaster.
8. Must be able to move intermittently throughout the workday.
9. Must have the strength and endurance require for sitting for lengthy periods of time.
10. Must possess sight/hearing Speech senses, or use prosthetics that will enable these senses to function adequately so that the requirements of this position are fully met.
11. Use appropriate body mechanics as needed for personal use.
12. Utilize appropriate basic office equipment.
Qualifications and Experience:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.
* Graduate of an accredited school of nursing with a minimum of a current RN licensure in the State of Nevada. * BSN or MSN preferred * Must have at least 5 years clinical nursing experience. * Minimum 3 years in a hospice quality role, leadership experience preferred. * Experience with working with hospice accrediting bodies * Ability to read, analyze and interpret business periodicals, professional journals, technical procedures, state and governmental regulations. * Must have reliable transportation and maintain current auto insurance. * Successful completion of background check pursuant to NRS 449.188 and NRS 179A.100 * Read, speak, write and understand the English language * Must be able to handle frequent interruptions, problem solve and have excellent follow through skills. * Must be able to cope with emotionally charged situations encompassing, patients, families and other caregivers as well as delegate and oversee staff effectively to maintain compliance etc. within the organization.
Minimum 5 years experience in Compliance, preferably within Hospice.
Must have an active Registered Nurse License for the state of Nevada.
Knowledge of Federal, State, Medicare, and Medicaid guidelines.
Must have strong computer skills.
Internal Number: CO2020
About ProCare Hospice of Nevada
We are a family owned and operated hospice operating in Clark and Nye Counties, Nevada. We are committed to the philosophy of compassion, comfort, support and dignity. Hospice believes that the quality at the end of life is as important as the length of it. We provide professional and ethical care to patients with a life-limiting illness or poor prognosis as well as provide on-going support and education to families and caregivers. Our staff is dedicated to educating the community about the benefits of hospice care. We strive to provide the most comforting end-of-life experience possible by valuing each patient as an individual.