732 Mott Street
Position Summary: The Senior Director of Quality Assurance is the key quality & compliance point person within the agency and plays an integral role in quality improvement planning, implementation, analysis, reporting and change management. Serves as Compliance Officer for the organization. Leads the NCQA accreditation readiness effort and has as a priority, the development of the agency-wide quality assurance plan.
Quality Assurance Management
A. Lead quality-related committees and workgroups, including: policy committee, QAPI committee, and evidence committee. With the assistance of administrative support staff:
1) Create agendas in collaboration with VP & QI consultant
2) Schedule meetings per policy and need
3) Ensure committee/team members have required materials, including minutes from previous meeting, in advance of all meetings
4) Assure maintenance of logs, minutes, sign-in sheets, and records for all meetings
B. Ensure that Quality Improvement Reports (QIRs) are reviewed and action taken where needed.
1) Lead investigations – determine appropriate investigation team, convene workgroup, collect materials, lead or facilitate root cause analysis, complete reports, track follow-through by exec team or other leaders.
2) Complete the investigation and intervention portions of the online QIR
3) Analyze and report trends in QIRs and convene special quality improvement teams to recommend interventions to resolve causes of repeated issues, errors or violations.
C. Serve as Compliance Officer for Partners in Care Foundation
Create, implement internal audit processes and systems to monitor compliance at the contractual, program, departmental and organizational levels.
Proactively obtain necessary documentation from program/department heads for review. Determine action items and remedies needed to ensure compliance with policies, regulations, and contracts with healthcare payers/providers.
Ensure that proactive vendor, network member and system audits are conducted; lead development of checklists for compliance audits and other performance improvement initiatives.
Respond to alleged violations of rules, regulations, policies, procedures, and standards ensuring initiation of investigative procedures. Develop and oversee a system for uniform handling of alleged violations.
Ensure appropriate development of Corrective Action Plans when an external authority has identified a systemic violation or omission. Ensure CAPs are communicated to NCQA.
Coordinate and facilitate communication to senior management regarding safety and compliance risks identified through QIR investigations and audits or by staff.
Review investigation findings and work with other leaders to formulate recommendations to improve the quality of care coordination and services.
D. Ensure feedback is given to submitter and that overall QIR work is publicized within the organization. Notify VP & CEO of issues and engage them to build ownership of quality improvement efforts throughout the organization.
E. Manage use of data for the quality assurance system; document internal compliance processes.
F. Deploy Kaiser Quality Improvement Advisors to forward systematic quality approaches within major program/operational departments, deepen analytical approaches for QAPI and participate in QIR investigations and root cause analyses.
G. Prepare regular and ad hoc reports to evaluate events, incidents, queries, and complaints. Participate in analysis, identification of trends, and assist staff with use of QA data.
H. Maintain current knowledge of relevant industry policy standards through legislation, industry agencies, and county, state, and federal guidelines. Stay up to date on relevant legislation, accreditation standards and compliance issues.
I. Compile and prepare compliance materials for submission to contract holders, regulatory agencies & NCQA; maintains schedule of agency-wide audits and performance status reports.
J. Serve as member of agency committees to support and prepare policies and procedures. Ensure implementation of policies as part of quality effort.
K. Ensure regulations and quality standards are communicated to relevant staff through appropriate training on policies and procedures.
1) Manage timetable for needed revisions to existing P&Ps, in collaboration with key staff involved in the relevant subject area;
2) Draft &/or review new policies and procedures;
3) Assist with the rollout and monitoring new policies and procedures.
L. Lead the development of organization-wide, departmental and Partners at Home Network quality management plans.
M. Assist with planning and implementation of inter-agency training of PAH Network staff on quality-related policies and practices.
N. Plan and participate in the process of evaluating agency QA/QI initiatives and strategies.
O. Serve as leader of the agency QA training team;
Select or prepare training modules to deliver to employees, volunteers, PAH network members or interns.
Schedule, deliver, and track QA training presentations, ensuring that needed content, delivery methods and tools, and training sessions are available on-demand and on-schedule.
Measurement Evaluation & Reporting [SA1]
A. Assist in identifying service delivery targets, staff performance indicators and outcome measures to evaluate program effectiveness and impact.
B. Assist in the development of surveys and evaluation tools that will produce quantitative and qualitative data and findings to validate compliance with standards of care for services.
C. Research potential industry or cross-organizational benchmarks for key success indicators.
D. Incorporate healthcare industry goals and contracting incentives (e.g., reducing readmissions, HEDIS measures, etc.) in design of metrics for Partners’ programs
E. Work with key agency staff during proposal development and during contract negotiations to identify clear, achievable success measures and the structuring of appropriate data collection systems prior to implementation.
F. Assist in selecting useful data collection instruments and in establishing processes to maximize efficiency and improve workflow. Assist agency staff with the development of presentations and the selection of data visualization that aids informed decision making and effective story-telling.
G. Coordinate the process of data collection and the analysis of data by internal staff and outside consultants.
H. Oversee the development of agency-wide dashboards and ensure timely communication of crucial data to upper management.
Education, Experience & Competencies
1) Master’s Degree (in human services or health-related field, such as Public Health, Social Work, Health Administration) &/or strong experience/training related to quality improvement, measurement and evaluation;
2) 8 years of work experience with at least 2 years of involvement in QA-related initiatives.
3) A passion/desire around Quality Improvement practices and how to implement Quality and compliance throughout an organization in all areas of business.
4) Experience working in a community-based organization providing or managing home and community-based services
5) Critical thinking and analytic skills acquired through program and/or project implementation and management;
6) Ability to remain objective, maintain authority and lead deep QA inquiry within a close, collegial staff culture;
7) Experience applying QAPI methodology of Plan, Do, Study, Act on a routine basis and working with staff to sustain or bring about change;
8) Experience in quality management in a healthcare, social service or other care/service setting;
9) Familiarity and experience with the principles of CQI, e.g., root cause analysis, brainstorming, cause and effect analysis, and graphic representation of data;
10) Experience winning accreditation;
11) Exceptional communication and customer relations skills;
12) Sound decision-making skills;
13) Effective in adult learning/training methods and practices and in all training modalities;
14) Experience with direct training of staff on policies and procedures, and monitoring adherence to policies and standards;
15) Cultural sensitivity with the ability to communicate orally and in writing to individuals and groups of varying cultural, ethnic, and educational backgrounds.
“Equal Opportunity Employer /Minorities/Women/Veterans/Individuals with Disabilities/Gender Identity/Sexual Orientation”
Excellent benefits package including medical, dental, vision, life insurance and 401 K.
Minimum Education Required