Director, Performance Improvement Center for Families and Children -
Cleveland, OH
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JOB SUMMARYUnder the supervision of the Vice President of Performance Improvement develops, implements and reviews at least annually an Organization performance improvement plan that produces measurable improvement results. Develops, implements and reviews at least annually an Organization compliance and risk mitigation plan to support continuous improvement and limit exposure and prevent loss of reputation, vital resources and ability to operate. Directs Organization functions including performance improvement, risk management, regulatory compliance, infection control and outcome measurement. JOB DUTIES & RESPONSIBILITIESPerformance Improvement responsibilities include: • Management of the Organization performance improvement plan that includes the strategic alignment, design, management, and evaluation of projects that solve performance problems, improve existing performance, and plan for changes and new performance.• Reporting status of performance improvement projects on a regular basis to senior management.
Evaluating the effectiveness of performance improvement projects and collaborating with project sponsors to implement changes that have been shown to be effective and support continuous learning. • Directing the process for data collection, data governance, analysis, evaluation, and reporting for Organization client outcomes and service utilization data.• Reporting client outcomes and service utilization data on a regular basis to senior management using a dashboard or scorecard approach. • Advancing a performance improvement culture through training and participation of staff at all levels of the Organization in performance improvement initiatives. • Conducting additional research regarding best practices and other interventions that are expected to improve results and incorporate these into performance improvement initiatives.• Collaborating with persons responsible for training and development to develop action plans designed to improve performance results.
Supervising performance improvement managers. Compliance and Risk Management responsibilities include:• Management of the Organization risk management plan that includes an infection prevention and control plan and associated surveillance activities, insurance and liability issues including adequacy of insurance carried by the Organization, health and safety, use of facilities, and the role and impact of health information technology and other service technology in ensuring effective risk assessment and mitigation.• Execution and monitoring of risk mitigation strategies through compliance, ethics, and training activities directed at high risk areas.• Chair the staff Risk Management Committee. • Management of the Organization compliance plan that includes licensing and mandatory reporting laws, fiscal accountability and governance, contracting practices and compliance, and other legal requirements.• Documenting the implementation of Organization policies regarding compliance with laws and regulations, ethics, staff conduct, conflicts of interest, and the investigation of misconduct or fraud.• Examination of emerging best practices in compliance risk assessment and monitoring U.S. Department of Health and Human Services (HHS), Office of Inspector General (OIG) and Office for Civil Rights (OCR) audit work plans and compliance program guidelines.• Conducting a comprehensive internal compliance audit and risk assessment at least annually in partnership with billing, program, and performance improvement managers that includes a review of work flows and internal monitoring and controls.
Ensuring readiness for Joint Commission, NAEYC, and other accreditation or certification and directing activities pre and post survey.• Directing the agency Client Rights Officer and the process for receiving, investigating, and resolving internal investigations related to client allegations, complaints, and grievances made by clients and others in the community. • Directing the process for receiving, investigating, and resolving internal investigations related to incidents.• Reporting on a regular basis the findings and actions taken as a result of external audits and reviews.• Serving as the Organization Compliance Officer and Privacy Officer and collaborating with the Organization Security Officer, Safety Officer, and persons responsible for grants management.
National Association for Healthcare Quality - 10 months ago
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