Specific Responsibilities:
Support program staff to meet Federal, State and local codes and regulations and accrediting body standards for “Best Practice” including but not limited to the Council of Accreditation and Praesidium.
Facilitate the preparation of Annual Action Plans, in support of long range strategic planning, for submission at the beginning and end of the year.
Conduct or oversee Case Record Review activities including but not limited to preparing quarterly and annual Case Record Review reports, aggregating data, analyzing trends, and working collaboratively with program staff regarding follow-up activities and improvements, as required.
Coordinate and/or conduct Consumer Safety activities including: investigations/assessments and evaluations; incident/accident/grievance tracking; Incident Review and minutes, case reviews related to critical incidents; working closely with Central QI on incident management requirements.
Coordinate and/or prepare quarterly and annual Consumer Safety reports, aggregating incident /accident /grievance data, analyzing quarterly and annual trends and working collaboratively with program staff regarding follow-up activities and improvements.
Conduct and/or coordinate the implementation and on-going administration of annual Customer Satisfaction Surveys within areas of program responsibility, aggregating data, analyzing Customer Satisfaction Survey trends.
Monitor Internal Quality Monitoring activities and prepare quarterly and annual reports capturing Key Performance Indicators and other quality improvement data involving, analysis of trends and patterns. Working collaboratively with program staff regarding follow-up activities and improvement opportunities, as required.
Facilitate Outcomes and Performance Measurement activities, including and the submission of Outcome Measures. Track key Outcomes and Performance measurements throughout the year,
Develop, as needed, and/or utilize agency systems for on-going program data collection and trend analyses, implementing procedures to use such systems in areas such as: demographics, consumer safety, consumer satisfaction, etc.
For all QI Activities, aggregating data, analyzing patterns and trends at least quarterly and annually, working collaboratively with program staff regarding follow-up activities and improvement opportunities.
Assist with the formulation, implementation and monitoring of corrective actions to ensure program improvement including but not limited to: policy/procedure development and review, systems development and review, establishing benchmarks, etc., tracking the implementation of corrective actions providing follow-up, as needed, with program staff.
Participate in and/or lead Quality Team meetings. Communicate results and recommendations to key audiences including the presentation of Quality Improvement reports to staff with analysis of trends and patterns and recommendations for improvement. Assure recording of minutes, as appropriate.
Participate in and provide leadership in all re-accreditation activities in which the department programs participate.
Participate in meetings or committees, as the position requires and as directed.
Other QI tasks as assigned.
Qualifications:
Master’s degree preferred in Human Services, Social Work, Health Care Administration, Public Administration or similar field. Three years of experience in quality improvement/program evaluation and/or administration, preferably in not-for-profit settings,
Skillset/expertise with computer database and word-processing programs such as MS-Office Suite–Word, Excel, Access to create and maintain databases, track and analyze information and data.
Experience with audit preparation, accreditation/survey activities, CQI/TQM, and Outcomes measurement, preferred.
Must be willing to travel the metropolitan NYC area and occasionally Long Island.
Relationship with Others:
Must be a team player and able to interact with the program’s leadership, supervisory and line staff, as well as with the agency Assistant Executive Directors for both Program and Quality Improvement and the Agency’s Central QI staff. Have a strong sensitivity to cultural differences in order to work well amongst staff, persons and families served and complete tasks as assigned. Ability to set limits, maintain role, work collaboratively and respectfully to intervene appropriately as a Quality Improvement Director.Demonstrate commitment to empower program management and staff through training and problem-solving in a strength-based environment