Statewide Director of Quality - Hospice of Michigan

Summary:

Under the direction of the Associate Vice President (AVP) of Quality and Compliance, responsible for overseeing the NorthStar Care Community (NSCC) quality programs. Acts as a convener, facilitator, collaborator, and coach to develop and drive a culture that values high quality of care and legal and regulatory compliance in all aspects of the organization.

Essential Functions:

• Ensures effective organizational strategic results are achieved, working collaboratively with others.
• Serves as the organization’s Statewide Quality Director.
• In addition to the quality team and infection control nurse, will oversee the Clinical Quality Nurse Specialists (CQNS).
• Oversees and participates in the development, maintenance, and continuous improvement of systems for auditing, monitoring, and tracking specific quality programs and issues, and distributes results to appropriate staff as needed.
• Acts as a liaison between internal leaders and surveyors in a consultative manner with onsite survey; participates in accreditation activities.
• Manages quality related processes including but not limited to policy/procedure review, publicly reported quality related measures (HCAHPS, HIS, HQRP, CMS Star ratings), etc.
• Analyzes health care quality metrics data to monitor compliance and identify trends.
• Leads statewide Quality Assurance & Performance Improvement (QAPI) efforts, including identifying opportunities for improvement through analysis of collected data, and coordinating with leaders to ensure QAPI efforts are integrated into all departments.
• Provides oversight for the collection, summarization, and analysis of quality and performance data (including CMS publicly reported data), provides statistical analysis, prepares/maintains routine reports and recommends opportunities for improvement.
• Participates in the development, maintenance and distribution of related policies and procedures for the organization.
• Proactively keeps abreast of hospice and palliative care trends, best practices, and any anticipated legal and regulatory changes. Takes appropriate action to ensure a culture of excellence is maintained.
• Collaborates with the Statewide Director of Compliance regarding organizational survey planning and preparedness activities.
• As directed by the AVP of Quality and Compliance, initiates and co-facilitates internal QAPI Committee activities and participates in Board level quality presentations.
• Proactively assesses, leads, participates, and promotes a culture of excellence and innovation at the employee, departmental and organizational levels, aimed at continually improving employee performance and engagement.
• Maintains oversight for recruitment and retention efforts consistent with the organizations vision, mission and values which ensure the engagement and retention of staff, within the designated area of responsibility, in collaboration with Human Resources.
• Proactively applies an inclusive management style and collaborates, as appropriate, with leaders, directors, and staff to ensure system linkage and integration.
• Effectively establishes, leads, facilitates, and participates in meetings at the individual, group and organizational levels, both within and external to the organization, with ease and comfort to achieve desired outcomes.
• Maintains oversight of all allocated resources within a designated area including but not limited to time, expenses, supplies and labor and ensures pre-determined financial margins and/or outcomes are achieved.
• Maintains oversight of all employee performance outcomes within the State of Michigan and ensures that a culture of accountability and responsibility is fostered to achieve desired performance outcomes and staff competency.
• Proactively works to coach and/or mentor direct reports and subordinates to improve performance. Ensures that appropriate corrective action and performance improvement plans are administered per organizational guidelines, when appropriate, in collaboration with Human Resources.
• Ensures internal and external education, training and activities for self and staff to promote personal and professional growth and to ensure staff competency is maintained at all times.
• Promotes NorthStar Care Community in all professional external and internal contacts. Proactively promotes census growth within designated area and seeks to offer care that meets the unmet diverse needs of the community.
• Models and promotes knowledge of palliative care and hospice philosophies and articulates and promotes the organizations vision, mission, and values locally, statewide, and nationally, when appropriate.
• Proactively participates and collaborates externally, with various individuals and/or groups, to establish various benchmarks and standards as it pertains to hospice and palliative care, locally, statewide, and nationally, when appropriate.
• Upholds the organizational Code of Conduct, policies and procedures and all regulatory and legal requirements.
• Models the NorthStar standards to care for every person, every time, 100% of the time.

Supervision: Reports to the Associate Vice President of Quality and Compliance. Direct reports include quality nurses, infection control nurse, CQNS, administrative assistant. Supervises, coaches and mentors all direct reports and is responsible for overall management of all staff within designated geographic regions(s) of responsibility.

Working Relationships:

Internal: Extensive contact with administrative, management and leadership staff across the organization both within the designated area of responsibility and with other individuals and departments within the organization.

External: Contact with community physicians, agencies, facilities, and other programs as needed, to promote growth and understanding of hospice and palliative care and ensure that service excellence is attained within the community. Collaborates with federal, State, and regional agencies as necessary.

Qualifications:

• A minimum of a Bachelor’s degree in a clinical and/or administrative field required. Master’s degree preferred.
• Minimum of five (5) years of experience in quality service improvement required.
• Three (3) to five (5) years of previous management experience that entails significant accountability for adherence to organizational quality goals and initiatives.
• Graduate of an accredited school of nursing with a current license to practice in the State of Michigan as a Registered Nurse required. Certification in hospice nursing (CHPN) preferred.
• Healthcare quality certification is required and should be in place upon hire or obtained within one (1) year of hire date.
• Operational experience in hospice/home care setting strongly preferred.
• Expertise in quality initiatives and standards as it pertains to hospice is required.
• Knowledge of business and management principles involved in strategic planning, resource allocation, human resources modeling, leadership technique, production methods, and coordination of people and resources required.
• Must possess emotional intelligence and the ability to promote positive, constructive relationships with communication and collaboration at all levels.
• Excellent interpersonal skills with the ability to comfortably interact at all social levels and with colleagues from many different backgrounds, ethnic origins and skill levels required.
• Must possess sound judgment; effective organizational, prioritization and follow-through skills; attention to detail; accuracy; dependability; tact; and ability to maintain confidential information.
• Understands performance improvement and can communicate and operationalize performance improvement initiatives at the departmental and organizational level. Demonstrated ability to produce results while still being a team player required.
• Ability to communicate effectively and professionally in writing and verbally to perform management duties and to promote good working relationships.
• Ability to effectively use technology in support of management and clinical operations.
• Must be able to read, write and speak English fluently and be able to communicate orally and in writing in internal and external relationships for all essential job functions.
• Ability to prioritize multiple demands. Demonstrates integrity and flexibility and participates actively in change and quality improvement initiatives.
• The physical demands of the position include: vision, effective speech and hearing for extensive telephone contact; repetitive motion; traveling; driving or riding in motor vehicle; standing, sitting, walking, bending, reaching, and stretching; lifting up to twenty (25) pounds unassisted.
• Must have reliable transportation in order to be able to travel and maintain the rigors of a busy schedule. Frequently works variable hours/days; activities and workload may require extended days.
• Must be physically and mentally capable of performing all essential duties required of the position.
• Must be eligible to work in the United States.

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