Director of Quality and Compliance

Job DetailsLevel: ExperiencedJob Location: Stockton Main Office - Stockton, CA 95204Position Type: Full TimeEducation Level: 4 Year DegreeSalary Range: $131,144.00 - $136,440.00 Salary/yearJob Shift: DayJob Category: Health CareHospice of San Joaquin is the oldest not-for-profit hospice, with over 46 years.  We serve all of San Joaquin and Stanislaus Counties.  We are committed to continuing to be the leader in ensuring the quality of the journey, from a serious illness to the end of life, and to honoring our mission by honoring life by ensuring patients and their Caregivers are the focus of everything we do.  We seek a Dynamic, self-motivated Director of Quality and Compliance who thrives in a fast-paced environment and supports our mission.

Sign-On Bonus:

***$1,000.00 for Registered Nurse  paid out in 2 equal payments over 12 months***

JOB SUMMARY AND SCOPE: The Director of Quality and Compliance (DQC) develops, implements, and maintains an effective and ongoing hospice-wide, data-driven Quality Assessment Performance Improvement Plan that meets the CMS/Joint Commission Standards: Program Scope, Program Data, Program Activities, and Performance Improvement Projects. The DQC will report to the QAPI Committee on the findings from Quality Assurance audits.

The Director of Quality and Compliance is responsible for overseeing the administration and implementation of the Compliance Program for Hospice of San Joaquin. The DQC shall report quarterly to the QAPI Committee on the operation and findings of the Legal Compliance Program. As such, the DQC will have broad autonomy to review any aspects of Hospice of San Joaquin’s billing, charting, and other Agency areas as the DQC deems appropriate to determine the level of Hospice of San Joaquin’s Compliance Program. The DQC shall report to the CEO regarding all day-to-day personnel issues, but to the Board of Directors for Compliance Complaints and investigations. 

QUALITY IMPROVEMENT: Responsible for the implementation and monitoring of the organization’s quality assessment performance improvement (QAPI) program, including infection control and OSHA.

a) Defines data elements, plans, prepares, and leads the quarterly Quality Assessment Performance Improvement (QAPI) meetings. Provides direction and coordination of QAPI activities utilizing continuous quality improvement principles and methodologies.

b) Compiles, trends, analyzes, and reports quality data in the following areas: patient care, safety, risk management, infection control, outcomes, HR, Volunteer, billing, and customer satisfaction. When a GAP is present, develops a PIP. Data is analyzed and compared internally and externally with other sources when available.

c) Develops and tracks ongoing Agency Performance Improvement Projects (PIPs) and designates appropriate managers or staff to conduct performance improvement projects, based on QAPI and benchmarking data.

d) Facilitates comprehensive chart audits for ALL teams and programs, utilizing the Hospice Clinical Record Audit Tool by the Joint Commission.

e) Works collaboratively with nursing supervisors to ensure documentation is complete and consistent with care and reflects legal requirements. Performs Clinical on-site visits to audit adherence to Conditions of Participation as needed.

f) Investigates and tracks serious adverse events/incidents/unusual occurrences, develops corrective action plans in conjunction with the CEO and CCO, and reports as appropriate to outside agencies.

g) Collaborates with management staff in the follow-up of concerns expressed by patients, families, and physicians.

h) Maintains the agency’s Required Reports Document and follows up with directors monthly to ensure compliance with all reports. All non-compliance items are reported to the CEO.

i) Oversees the HIS data comparison and the Hospice CAHPS submissions.

EDUCATION: Designs and oversees the staff education program, and ensures all compliance items are met. Collaborates with Clinical Educators to provide a process to promote and ensure employee orientation, competency (skills lab), and in-service education programs. Ensuring that these programs remain updated to changes in regulations, and in response to employee surveys, CAHPS scores, and PIPs.

j) Assists in the identification of skills for annual competency and provides in-service training support.

k) Ensures HHA/CNA are compliant with State CEU requirements.

l) Maintains agency CEU Licensing program. Coordinates with CCO and Medical Director to provide two (2) CEU courses a year.

m) Oversees the administration of the Relias education system.

COMPLIANCE: As Compliance Officer, ensures compliance plan includes all elements, compliance line is available for staff and patient reporting, and investigates issues. Monitor organization compliance with regulatory and accreditation standards.

n) Maintains current knowledge related to Medicare Conditions of Participation and the Joint Commi