Director of Organizational Excellence

Job Summary:

Manages and coordinates organization-wide efforts to ensure that educational and quality improvement (QI) programs are developed and managed using a data-driven focus that aligns with organizational mission and vision, and sets priorities for improvements aligned to ongoing strategic imperatives Assures that organization-wide QI initiatives are focused and aligned on improving operational and program efficiencies and effectiveness and meeting regulatory requirements. Participates in organizational strategic planning and provides leadership for QI policy development.

Duties and Responsibilities:

Participates in decision-making and provides recommendations to the leadership team on QI needs and provision of high quality clinical services that are cost-effective and aligned with the agency’s strategic plan.

Works closely with the leadership team and clinical and administrative managers to establish QI standards and measures, and to design and implement effective processes and programs to improve quality of care and ensure compliance.

Directs, develops and coordinates the PI program to promote the goals and objectives of the organization in compliance with all professional , regulatory and accreditation standards.

Develops a Home Health Value-Based Purchasing (HHVBP) Road Map to drive the organization toward optimal HHVBP results.

Monitors and reports on all publically reported experience data (Hospice and Home Health).

Oversees and monitors the QAO compliance process.

Chairs agency Quality Meetings and other assigned committees.

Coordinates efforts to ensure that all accreditation and regulatory requirements are in compliance.

Responds to all regulatory inquiries/surveys.

Responds to quality-of-care issues from insurers, patients, patient representatives and referral sources.

Conducts root cause analysis as needed.

Orients new employees to quality improvement.

Provides supervisory oversight for quality team.

Coaches and mentors staff.

Manages the agency’s event reporting system and facilitates the process of reviewing and trending all events. Provides feedback to staff and develops and implements improvement plans as needed.

In conjunction with Kent Hospital’s Risk Manager serves as VNA of Care New England’s Risk Manager, liaison to CNE Risk Management, serves on CNE Risk Management Committee.

Works closely with CNE Risk Management on risk issues identified and prevention activities.

Assists in the implementation of CNE Risk Management initiatives and compliance programs at the VNA.

Identifies opportunities to manage risk though events/clinical records review and observations.

Oversees the assessment of agency educational needs and the development, implementation and evaluation of educational programs.

Ensures programs are aligned with organizational needs.

Provides input to organizational goals based on quality results, regulatory requirements or outcomes.

Provides managerial oversight to Medical Records on an as needed basis; supports the orientation and education of Medical Records staff.

Ensures all regulatory auditing by Medical Records is accurate and complete.

Works closely with Medical Records for all ADRs and medical record requests. Prepares and reviews all requests prior to submission.

Ensures that experience data is collected and shared with workforce and leadership team.

Provides input and leadership for initiatives to improve experience.

Participates on the experience committees/councils both at agency and system level.

Monitors and reports on all publically reported experience data ( Hospice and Home Health.)

Serves on appropriate agency, CNE and other external committees.

Requirements:

Master’s degree in related field required.

Certified Professional in Healthcare Quality (CPHQ) certification preferred; CPR Certification Required

Minimum of three (3) years progressive management experience in a hospital/health care environment required. Previous clinical background and acquired health care quality indicator development background, preferably within a home health care environment.

Must possess a valid driver’s license and current automobile liability insurance.

Basic knowledge of group process and adult learning/teaching skills required.

Knowledge of home health and hospice accreditation and regulatory compliance standards required. Previous experience in or knowledge of