Quality Improvement Specialist

JOB SUMMARY

The Quality Improvement Specialist (QIS) works directly under the supervision of the Director of Compliance, who has overall responsibility to ensure congruence between St. Mary’s Home’s policies, procedures, and practices and St. Mary’s mission, vision, and values; and compliance with all federal, state, and local regulations. The QIS provides back-up for Risk Management duties.

PRIMARY RESPONSIBILITIES

Regulatory Compliance:

• Develop new and revise current operating policies and procedures as necessary to ensure compliance with current federal, state, and local regulations.
• Coordinate the full life cycle of policies, including providing information to policy owners as they draft and revise policies, supporting review by the Policy Committee by providing the agenda for the monthly policy review meeting, facilitating approvals and signatures, publishing policies, and archiving older versions.
• Maintain a separate Word directory of all policies, guidelines, and forms being used in the facility.
• Assist in the development, implementation, and monitoring of new processes, policies, procedures, guidelines, and forms.
• Act as a resource for answering questions related to ICF/IID regulatory standards, as well as state and local regulations.
• Assist with completion of paperwork during regulatory reviews (Life Safety Code inspections and ICF surveys).
• Ensure retention policies meet regulatory requirements and adherence of the organization to retention requirements.

Quality Auditing:

Perform utilization reviews of direct services delivered to individuals served at St. Mary’s to verify consistency between current practices and St. Mary operating policies and procedures.

• Complete quality improvement activities, collecting and analyzing data to implement positive change based on results.
• Design charts, graphs, and/or dashboards to communicate findings.
• Collaborate closely with the Director of Compliance in all quality assurance and compliance matters, reporting any concerns or gaps as soon as possible.
• Assist in the development of compliance and quality assurance training materials and perform quality assurance and compliance training as needed.
• Take the lead on obtaining systematic satisfaction data from people supported, employees, families, and other professional stakeholders.
• Perform reviews of all related services provided by St. Mary’s to ensure compliance with existing policies and procedures (i.e., Business Agreements, licenses and liability insurance annual requirements from contractual employees/companies).
• Provide regular reports on all review activities to immediate supervisor and other department managers as scheduled and offering consultation as needed.
• Provide ongoing advice and resources to the Director of Compliance and Senior Leadership team for compliance and quality assurance issues and processes while monitoring improvement and implementations.
• Research, analyze, and contribute to the development and implementation of new quality measures and methods.
• Review service documentation to ensure it is being done timely and correctly.
• Assist with safety reviews of the living environment.

Other Related Duties:

• Serve as back up for Risk Manager.
• Complete investigations of events as needed.
• Assist with inventory and fixed assets tracking.
• Performs other duties as assigned by the immediate supervisor.