Director of Quality Assurance Clinical

Purpose of Your Job Position

The primary purpose of your position is to plan, organize, develop, coordinate, and direct the Facility’s Quality Assessment and Assurance Program in accordance with current applicable federal, state, and local standards, guidelines and regulations, and as may be directed by the Administrator, to assure that the highest degree of quality resident care and safety can be maintained at all times.

Delegation of Authority

As Quality Assurance & Performance Improvement/Staff Development Director, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.

Job Function

Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or is an essential function of the position.

Duties and Responsibilities

Administrative and Surveillance Functions

• Plan, organize, and direct quality assurance programs and activities.

• Plan, organize, and director employees staff education/development activities.

• Plan, organize, and director employee health activities.

• Plan, develop, organize, implement, coordinate, and direct the quality assurance and assessment program designed to enhance the quality of resident care, in accordance with current rules, regulations, and guidelines that govern nursing care facilities.

• Evaluate programs and make changes, as necessary, to improve programs and assure compliance with regulatory requirements.

• Communicate revised plans and changes to Facility management to maintain awareness.

• Coordinate concurrent review studies performed within the quality assurance program and prepare resulting reports, as required.

• Establish and maintain tracking systems for recommendations of groups involved in quality assurance.

• Develop and implement appropriate plans of action to correct identified deficiencies.

• Maintain an adequate liaison with families and residents.

• Schedule committee meetings and notify members of such meetings.

• Assist in developing follow-up procedures for monitoring identified problem areas.

• Maintain a reference library of written quality assessment and assurance material, laws, etc., necessary for complying with current standards and regulations and that will provide assistance in maintaining quality resident care.

• Make written and oral reports and recommendations to the Administrator, as necessary or required, concerning the operation of the quality assessment and assurance program.

• Assume the authority, responsibility, and accountability of directing the quality assessment and assurance department.

• Assist in developing yearly evaluation schedules for departmental studies.

• Assist in identifying and classifying procedures in which potential exposure to blood or body fluids may occur. Update as necessary.

• Maintain committee minutes of meetings.

• Participate in Facility surveys, as necessary or as may be directed.

• Work with the Facility’s risk manager in reviewing policies and procedures, survey reports, etc., to ensure protocols are in place to aid in loss prevention.

Committee Functions

• Serve as chairperson of the Quality Assessment & Assurance Committee.

• Meet with the Quality Assessment and Assurance Committee monthly to review all assessment tools designed, all data collections reports, and all activities regarding quality assurance as carried out by departments, services, or committees that have a direct impact on resident care and safety.

• Attend various committees of the Facility (i.e., Pharmacy Committee, Safety Committee, Resident Care Policy Committee, etc.) as deemed appropriate, and as appointed by the Administrator.

• Assist other committees and departments in the development of monitoring tools, criteria and standards, assessment methodologies, and the evaluation and selection of priority concerns affecting resident care and safety.

• Serve as liaison among committees and/or departments to focus on quality assurance in the ongoing operation of the Facility.

• Implement recommendations from the Quality Assessment & Assurance Committee as they relate to the quality assurance program.

Staff Development

• Develop and participate in programs designed for in-service education, on the job training and orientation classes for newly assigned personnel. (Includes maintaining appropriate recordkeeping requirements of when classes were held, subject matter, attendance, etc.)

• Develop, implement, and maintain an effective orientation program that orients the new employee to the department, its policies and procedures, and to his/her job position and duties.

• Monitor and supervise work, evaluate performance, initiate or recommend personnel action such as merit increases, promotions, and disciplinary action.

• Participate and assist in departmental studies and projects, as assigned or that may become necessary.

• Attend and participate in workshops, seminars, etc., to keep abreast of current changes in the health care field, as well as to maintain a professional status.

• Attend and participate in annual Facility in-service training programs (e.g., OSHA, TB, HIPAA, Abuse Prevention, Safety, Infection Control, etc.).

• Assist in identifying areas in which training is needed.

Budget and Planning Functions

• Prepare and plan the quality assessment and assurance department’s budget and submit to the Administrator for his/her review, recommendation, and/or approval.

Resident Rights

• Review complaints and grievances made by the resident and make a written and oral report to the Nurse Supervisor, LPN, and RN. Follow Facility s established procedures.

• Maintain a written record of the resident’s complaints and/or grievances that indicates the action taken to resolve the complaint and the current status of the complaint.

• Report all allegations of resident abuse and/or misappropriation of resident property.

• Must adhere to all HIPAA requirements.

Working Conditions

• Works in office area(s) as well as throughout the Facility.

• Is involved with physicians, residents, personnel, visitors, government agencies or personnel, etc., under all conditions and circumstances.

• Communicates with the medical staff, nursing personnel, and other department directors.

• Attends and participates in continuing educational programs.

Education

• Must possess, as a minimum, an Associates Degree.

Experience

• Sufficient previous experience in clinical health care including direct experience in quality assurance.

Specific Requirements

• Must be able to read, write, speak, and understand the English language.

• Must possess the ability to make independent decisions when circumstances warrant such action in a timely fashion.

• Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government

• Must be knowledgeable of quality assessment and assurance procedures.

• Must be willing to seek out new methods and principles and be willing to incorporate them into existing practices.

Physical and Sensory Requirements

(With or Without a Reasonable Accommodation)

• Must be able to move intermittently throughout the workday.

• Must be able to see and hear or use prosthetics that will enable these senses to function adequately to assure that the requirements of this position can be fully met.

• Must meet the general health requirements set forth by the policies of the Facility, which may include a medical and physical examination.

• Based on the Occupational Safety and Health Administration's Guidelines for Nursing Homes Ergonomics for the Prevention of Musculoskeletal Disorders and the American Conference Governmental Industrial Hygienists' Threshold Limit Values for Lifting the Facility has identified that this job may require the lifting of residents, equipment, or other objects. Accordingly, this job may require a minimum of 5 pounds and a maximum of 25 pounds lifting, periodically and or as needed.