Director of Quality Management (Hospice & Palliative Care) at MJHS

The Director of Quality Management oversees the development, implementation and maintenance of quality management program for Hospice and Palliative Care. 

• Develops a Quality Assurance/Performance Improvement (QAPI) Plan for Hospice consistent with regulatory requirements, industry standards and patient needs
• Keeps senior leadership abreast of trends within healthcare quality, it’s impact on hospice, advises and recommends strategic quality initiatives. Reports on key quality indicators to Senior Leadership
  • Collaborates with leadership and hospice staff to develop clinical performance indicators, manage related analysis and benchmarking and disseminate information. Ensures quality and performance improvement data is used for statistical data and performance improvement.
  • Facilitates data collection and analysis
  • Collaborates with clinical and operational departments to ensure implementation of interventions
  • Utilizes PDSA methodology and analytical tools to evaluate results

• Oversees the utilization of On-Line Risk Management System (Safetrak). To identify and reduce risks by examining high risk, problem prone processes related to care, treatment or service

1. • Works collaboratively with the SVP in the development and evaluation of the QI program and evaluation in accordance with the organization’ s mission and goals and federal and state regulations.
   • Works to ensure data reporting needs are met
   • Ensures effective analysis of performance metrics in comparison to internal/external benchmarks and goals
   • Identifies opportunities for improvement and ensures appropriate interventions are implemented and evaluated

• Collaborate with the Patient Experience team and Customer Experience Department.
• Ensures the consistent development, implementation and accountability of performance improvement initiatives to enhance processes that support the provision of high-quality care and ensures effectiveness of performance improvement projects.
• Ensures compliance with Federal and NYS regulations by serving as a resource on regulatory matters
• Maintains knowledge of current trends and developments in areas of responsibility through membership in appropriate professional organizations, attend in services and continuing education to maintain current knowledge and expertise, maintain up to date knowledge of the laws regulation and payor requirements that affect policy and procedure
• Oversees CMS Hospice Quality Reporting Program (CAHPS and HIS) to ensure compliance with regulatory mandates. Utilizes data to implement Performance Improvement Projects in order to improve practice and service
• Manages performance of direct and indirect reports. Provides orientation, coaching, training and development. Take corrective action when necessary.
• Utilizes corporate services resources such as Human Resources, Compliance, Legal, Finance, Information Services, Marketing, etc., as appropriate.
• Ensures appropriate staffing and resources to support department/agency services. Monitors productivity throughout the year and participates in annual budget preparation.
• Interviews and participates in the selection process for qualified staff in collaboration with Human Resources and department management.