Purpose of the Position:  To conduct quality improvement activities within the Department/Division to help to ensure the quality of care and services of the persons and families served by the 29i medical program at SCO Family of Services.

 

Reports to:     Primary reporting to their program’s Supervisor/Director of PQI or in the absence of that position reporting to the Vice President who oversees their department.

 

Supervises:  N/A

 

Specific Responsibilities:

 

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

 

Collaborate with department directors and vice presidents to ensure preparation, coordination and follow up on external audit processes.

 

Facilitate activities in support of long range strategic plans.

 

Conduct or oversee 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.

 

Revise and maintain 29i Policy and Procedure Manual at least on an annual basis or when a major policy shift occurs.

 

Participate in all Quarterly Incident Review Committee meetings, and program IRCs as requested by the Director of Nursing or PQI Director.

 

Participate in Monthly Agency–Wide and Departmental Quality Improvement meetings.

 

Facilitate the submission of Outcome Measurement reports: 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.

 

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.

 

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.

 

Participate in Quarterly Quality Team meetings. Communicate results and recommendations to Directors of Mental Health and Quality Improvement, Vice President, etc. including the presentation of Quality Improvement reports to staff with analysis of trends.  Assure recording of minutes, as appropriate.

 

Initiates and maintains communication with other SCO Departments and/or external regulatory agencies, as directed and/or appropriate, to obtain clarification on issues which have an impact on PQI issues for the program/Department.

 

Other PQI 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.  One year’s 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, Electronic Health Records (specifically eClinical Works),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.

 

 

Relationship with Others:

Must be a team player, able to engage people throughout the agency in order to interact with Administrative and Managerial staff as well as Supervisory and Line Staff, as appropriate. 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 staff person.

 

Working Conditions:

Work conducted in office and program environments.

 

I have received and read this Job Description.  I have had the opportunity to ask questions and understand its contents and have had the opportunity to discuss any questions that I may have had.