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519 N. Union St. Olean, NY

QUALITY IMPROVEMENT MANAGER

BASIC PURPOSE & SCOPE:

Under the direction of the Director of Patient Care Quality is responsible for, but not limited to, the implementation and oversight of quality improvement programs.  Will recommend QI plan document(s) for adoption or revision, develop monitoring procedures, conduct and coordinate clinical record reviews on a scheduled basis, develop methodology for compliance with regulatory requirements pertaining to quality care in response to external survey or internally identified needs, and promote opportunities for patient/participant involvement with quality improvement issues. Responsible for the employee orientation and support of the electronic medical record (EMR) systems of the organization and its affiliates, in relation to clinical applications and policy. Responsible for assisting clinical staff education and development throughout agency.

RESPONSIBILITIES:

  1. Ensures completion of internal quarterly clinical record reviews in conjunction with supervisory staff.
  2. Develops and/or recommends internal caregiving policy and procedure to address new or changing needs and quality improvement components of agency operations.
  3. Conducts or coordinates scheduled and unscheduled monitoring of clinical records.
  4. Develops and implements direct patient/customer/participant survey methods to obtain quality improvement data.
  5. Promote high standards in quality of training and equivalency programs, orientation procedure, and quality of care delivered by employees.
  6. Prepares monitoring, survey, and clinical record review reports.
  7. Maintains agency quality improvement records, including QI plan documents, and coordinates timely updates to policy and procedure manuals.
  8. Serves as staff liaison to Quality Improvement Committee(s).
  9. Ensures completion of data collection, entry, and reports required for managed care quality improvement programs.
  10. Provides programmatic supervision to nursing management regarding clinical policy and protocol matters.
  11. Directly provides and/or oversees training on the EMR as part of new employee orientation.
  12. Maintains communication approach for employee access to assistance with EMR application.
  13. Maintains a log of queries made regarding EMR utilization to address trends or need for IT department follow-up.
  14. Provides opportunities for employee development and education to enhance the integration of EMR with all clinical activities.
  15. Develops approaches to evaluate EMR employee competencies.
  16. Responds to identified employee deficiencies in the use of the EMR as requested by supervisory staff and provides follow-up.
  17. Develops, implements, and maintains EMR policies through QI department
  18. Provides direct supervision, training and evaluation of quality improvement staff and other staff as may be assigned.
  19. Participates in providing agency in-services for further staff development and orientation programs as applicable and assigned under the direction of the Director of Patient Care Quality.
  20. Provides Nursing staff orientation and training as assigned.
  21. Coordinates the organization’s emergency and disaster preparedness plan, conducting intermittent drills to insure adequacy and appropriate staff training.
  22. Oversees and conducts quality improvement activities, external to agency functions as may be assigned.
  23. Communicates information from agency committees to leadership for discussion/ consideration; especially as it pertains to agency planning and needs.
  24. Adheres to and reflects organizational values in daily work.
  25. Serves on agency committees as may be assigned.
  26. Maintains an obligation to report wrongdoing/violation of agency policies, applicable federal, state, and local laws, and rules and regulations pertaining to agency operations, to immediate supervisor or identified compliance officer.
  27. Completes all mandatory inservice education programs and completes any other additional inservice hours that are minimally required for the position.

The above examples of work may not be a complete statement of all assignments that may be inherent to the position.  Other duties may be assigned as deemed necessary and appropriate by the Director of Patient Care Quality or Administrator/CEO.

MINIMUM REQUIREMENTS:

      1.   Associate’s degree in nursing; BSN preferred; with current NYS nursing registration.

      2.   Three years nursing experience, preferably in hospice or home care, with at least 1 year of the minimum required experience involved with the management and/or delivery of quality improvement programs, studies, or initiatives.

      3.   Knowledge of quality improvement program design, execution, and reporting.

      4.   Demonstrated supervisory and organization skills.

      5.   Effective verbal and written communication skills, including computer literacy and familiarity with data collection and presentation.

      6.    Acceptable driver’s license and automobile available for use with current insurance.

      7.    Use of telephone.

      8.    Successful completion of NLN proficiency in medication administration exam.

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