The Quality Assessment and Performance Improvement (QAPI) Specialist is responsible for the Quality Program at the hospice subsidiary, including all subsidiary sites. He/she identifies areas of program strength and areas of improvement, oversees the collection and aggregation of performance improvement data for all sites within the subsidiary, analyzes data, defines desired outcomes, and develops recommendations that improve patient outcomes, maximize resource utilization, and complies with all applicable standards and regulations. Partners with site management in evaluating best practices, ongoing quality and compliance measures, staff orientation and excellence in hospice care. Standardizes processes through effective utilization of measured outcomes. Prepares high level reports for the Quality (QAPI) Committee of the Board and for the Board, including recommendations for actions to be taken by management. Provides staff education related to QAPI and Regulatory Standards. Has strong liaison relationship with Corporate Quality to ensure excellence in knowledge base and techniques.
- Bachelor’s degree in Nursing or 2 years’ experience working with Quality and Performance Improvement including assimilating quality data plus proficiency in Excel; Master’s Degree in healthcare field preferred
- Minimum two (2) years’ related experience with knowledge of Quality Assessment & Performance Improvement
- Certifications preferred
- Six Sigma
- Certified Professional in Healthcare Quality (CPHQ)
- Strong business foundation with proven analytical and problem-solving skills required.
- Demonstrated experience with statistics, data analysis and outcomes management is required.
- Excellent verbal and written communication skills.
- Ability to utilize analytical and statistical tools.
- Knowledge of and ability to apply process improvement theory and process mapping.
- Computer knowledgeable and competent with statistical applications and graphics.
- Valid Florida Driver's license and automobile insurance.
- Able to travel to off site locations
- Able to work with minimal supervision and exercise a high degree of discretion and independent judgment.
- Able to prioritize multiple job responsibilities and exercise critical thinking skills.
- Satisfactory completion of competency requirements for this position.
- State and Federal regulation knowledge.
- Joint Commission Hospice Standards and the National Patient Safety Goals.
Responsibilities of all employees:
- Represent the Company professionally at all times through care delivered and/or services provided to all clients.
- Comply with State, federal and local government regulations, maintaining a strong position against fraud and abuse.
- Comply with Company policies, procedures and standard practices.
- Observe the Company's health, safety and security practices.
- Maintain the confidentiality of patients, families, colleagues and other sensitive situations within the Company.
- Use resources in a fiscally responsible manner.
- Promote the Company through participation in community and professional organizations.
- Participate proactively in improving performance at the organizational, departmental and individual levels.
- Improve own professional knowledge and skill level.
- Support Company research and educational activities.
- Share expertise with co-workers both formally and informally.
- Participate in Quality Assessment/Performance Improvement activities as appropriate for the position.
Job Specific Responsibilities
Quality Assessment & Performance Improvement (QAPI) Including Patient Safety
- Provides consultation and training for Performance Improvement (PI) teams at all sites. Functions as team leader or facilitator as needed.
- Identifies, designs, and leads performance improvement initiatives.
- Collaborates with Director of Corporate QAPI/Risk Management as needed to facilitate team activities relative to QAPI Initiatives & Patient Safety Initiatives
- Reviews and researches materials for QAPI/Safety activities.
- Utilizing appropriate statistical tools, interprets data and draws relevant conclusions on effectiveness of improvements.
- Prepares QAPI reports and provides facilitation and direction for Performance Improvement Projects (PIP's)
- Coordinates subsidiary's quality indicator selection and implementation of measurements.
- Partners with Management in obtaining and developing benchmarks (internal & external.)
- Monitors patient/family and other customer satisfaction levels; develops tool for monitoring patient outcomes.
- Teaches others to utilize the QAPI process and statistical tools.
- Represents the subsidiary for various corporate meetings, initiatives and projects, as directed.
Joint Commission (TJC)
- Responsible for ensuring regulatory and accrediting surveys and audits including TJC Periodic Performance Review (PPR)
- Develops documentation and other processes designed to assure attainment of TJC standards.
- Leads activities designed to assure continued accreditation.
- Coordinates implementation of TJC National Patient Safety Goals, ORYX Indicators and CMS required reporting.
- Manages data aggregation to meet TJC standards.
- Responsible for organizational attainment of TJC standards which includes data collection, analysis and communication of findings to appropriate departments and education of staff.
- Enhances professional expertise and competency through education and training.
- Assumes responsibility as a self-directed professional for own continuing education.
- Identifies needs or seek direction in identification of needs to maintain expertise and keep current with health care
trends and practices.
- Promotes the Hospice concept in the community by participating in the development of educational materials and offerings for both the public and medical community.
- Provides consultation to department managers, preceptors, patient care managers, and other health care professionals within the organization.
- Evaluates the effectiveness of processes for patient outcomes, staff development and maximization of financial
- Participates in orientation and education of staff at all levels relating to quality assessment and performance improvement and Joint Commission compliance.
- Collaborates with corporate in trending quality outcomes. Utilizes Ethics Point to track and trend opportunities to improve quality of care.