SPECIFIC RESPONSIBILITIES:

1. Assist program staff to meet Federal, State and local code and regulations and accrediting body standards.

2. Facilitate the preparation of Annual Action Plans, in support of long-range strategic plans, for submission at the beginning and end of the year, as well as quarterly reporting.

3. Conduct Case Record Review activities and prepare 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.

4. Coordinate and/or conduct Consumer Safety activities including the following: investigations/assessments and evaluations of critical/serious incidents, accidents and grievances; incident/accident/grievance tracking; case reviews related to incidents; working closely with the Incident Management Unit on incident management requirements.

5. 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.

6. Prepare for, schedule and conduct program Incident Review Committee (PIRC) meetings, at least quarterly but usually every other month, if necessary.

7. Conduct and/or coordinate the implementation and on-going administration of the Customer Satisfaction Surveys; aggregating data, analyzing trends and working collaboratively with program staff regarding follow-up activities and improvements, as required. Prepare the Consumer Satisfaction Survey report and feedback mechanism.

 

8. Prepare quarterly and annual Internal Quality Monitoring reports capturing key program indicators and other quality improvement data involving trends and working collaboratively with program staff regarding follow-up activities and improvements, as required.

9. Facilitate the submission of Outcome Measures: Track key Outcomes and Performance measurements throughout the year, aggregating data, analyzing quarterly and annual trends and working collaboratively with program staff regarding follow-up activities and improvements.

10. Develop, as needed, and/or utilize agency systems for on-going program data collection and trend analysis, implementing procedures to use such systems in areas such as: demographics, incidents and accidents, the conduct of investigations, program specific demographics, etc.

11. 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, personnel assignments, training, etc., tracking the implementation of corrective actions providing follow-up, as needed, with program staff.

12. Participate in Quality Team meetings. Communicate results and recommendations to key audiences including the presentation of Quality Improvement reports to staff with analysis of trends. Assure recording of minutes, as appropriate.

13. Ensure the implementation requirements, as indicated in the agency Quality Improvement manual.

14. Assist program staff with updating the Program Manual ensuring new/updated regulations and protocols are entered.

15. Coordinate and assist with reaccreditation preparation activities (Council on Accreditation and Praesidium).

16. Complete all mandatory and assigned training requirements.

17. Other QI tasks as assigned.

QUALIFICATIONS:

Bachelor’s degree required. 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 in not-for-profit settings preferred. Experience 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, desirable. Experience with audit preparation, accreditation/survey activities (especially COA), TQM, CPI and Outcomes measurement is desirable. Three years of experience with OMH, OASAS, NYSED, OCFS or Care Management Health Homes and DOH regulations. Good oral and written communication skills.

 

RELATIONSHIP WITH OTHERS:

1. Must be a team player, able to engage people throughout the agency, to interact with Administrative and Managerial staff as well as Supervisory and Direct Care Staff, as appropriate.

2. Have a strong sensitivity to cultural differences to work well amongst staff, persons and families served and complete tasks as assigned.

3. Ability to set limits and boundaries, maintain role, work collaboratively and respectfully to intervene appropriately as a quality improvement staff person.

WORKING CONDITIONS:

1. Work conducted in office and program environments.

2. Must be willing to travel to other facilities in Queens and Brooklyn