Associate Executive Director of Continuous Quality Improvement/Staff Development/Safety
Quality Improvement
JOB SUMMARY
This position directs the development, implementation, review, and modification of the agency’s Continuous Quality Improvement Plan and provides support for the development and implementation of the agency’s safety goals (including occupational safety) and staff development.
MAJOR DUTIES
- Participates in the planning, formulation, and implementation of Alabama Department of Mental Health (DMH) contracts.
- Ensures agency compliance with agency policies, Medicaid, Alabama Department of Mental Health (DMH) guidelines/life and health standards, Alabama Board of Nursing Standards and Practices, federal, state, and local safety laws, regulations, codes, and rules, including, but not limited to, OSHA, Fire Department, USDA/Public Health Department, and Department of Transportation guidelines.
- Manages the assessment of agency outcomes and goals; assists the Executive Director in the identification of programmatic and administrative outcome goals and objectives; establishes specific measurement criteria for outcome goals and objectives; establishes efficient and effective measurement procedures for each identified outcome; gathers data according to procedures; summarizes and presents data to management.
- Manages the provision of staff development training; provides initial, annual, and specialized staff training for agency programs and services.
- Identifies departments’ safety training needs and ensures the provision of that training.
- Provides and coordinates work site safety training for all agency personnel on shifts and at all locations.
- Submits recommendations to the Executive Director for the development, evaluation, or revision of agency policies, procedures, or rules which would improve program services, safety and/or occupational health issues for the agency.
- Conducts safety surveys and inspections; submits written reports of findings to the Executive Director on matters such as repairs, damages, unsafe work conditions, or corrective or preventative measures needed; follows-up to ensure measures were implemented and remain in place; intervenes, if necessary, to stop any operation or activity that constitutes an imminent hazard.
- Surveys the satisfaction of persons served; develops, modifies, or utilizes approved person/family survey instruments to assess satisfaction with services; analyzes survey information and assists in the development of system improvement strategies.
- Coordinates the agency’s Incident Identification and Management System; designs and implements electronic incident reporting and tracking system; analyzes incident data, identifies trends, and makes corrections for corrective actions to management.
- Oversees and investigates incidents and accidents involving personnel and other safety investigations as needed and reports findings and recommendations to the Executive Director; maintains confidential information pertaining to agency safety incident and accident investigations; analyzes and interprets accident data; designs and implements safety incident and accident reporting and tracking system.
- Monitors services to ensure quality and compliance with contractual standards and obligations; samples and reviews files of persons receiving services on a regular and systematic basis and reports compliance with documentation requirements to the Executive Director; monitors other administrative systems for policy compliance and communicates findings to the Executive Director; reviews persons’ files to ensure that identified needs are addresses and that recommended services are being provided; interacts and communicates with persons; monitors planning and services to ensure that persons are afforded their rights; prepares for and assists in inspections and responds to recommendations resulting from periodic site reviews (DMH, Medicaid, Alabama Disability Advocacy Program, etc.)
- Maintains certification in CPR, First Aid, Medication Assistance (MAC), and as a CPI Instructor.
- Ensures the completion and maintenance of required documentation and records; ensures that charts, graphs, reports, and other reports are accurate and completed in a timely manner.
- Ensures that recommendations from Alabama DMH, ADAP, DHR, and Medicaid reviews are provided to the Executive Director.
- Ensures the preventive maintenance process for property, materials, and equipment, to include safety and security monitoring systems, comply with all applicable safety guidelines and requirements.
- Develops agency emergency evacuation plans and ensures the availability of related equipment and supplies.
- Assists Associate Executive Directors in becoming effective safety leaders through the development of safety goals and the implementation of employee training programs.
- Provides support and guidance to agency personnel on safety-related issues.
- Prepares and distributes monthly safety information, including safety-related statistical data, to agency employees to ensure understanding of and compliance with safety regulations.
- Ensures required safety drills are conducted, accurately documented, and properly reported.
- Serves as the agency’s Safety Coordinator; chairs agency-wide Safety Committee comprised of agency Associate Executive Directors; conducts monthly meetings; submits minutes to Executive Director; serves on the agency’s Incident Identification and Management Committee
- Performs the duties of the Executive Director in his or her absence as assigned.
- Performs other duties and responsibilities deemed necessary; not otherwise specified..
KNOWLEDGE REQUIRED BY THE POSITION
- Knowledge of agency policies and of Alabama Department of Mental Health and Medicaid guidelines.
- Knowledge of the nature of intellectual disabilities and related clinical and sociological issues.
- Knowledge of quality assurance principles and practices.
- Knowledge of safety and risk management principles and practices.
- Knowledge of program/service review and modification principles and practices.
- Knowledge of computers and job-related software programs.
- Skill in investigating accidents and incidents in the collection, analysis, and reporting of data.
- Skill in preparation and delivery of safety training.
- Skill in problem solving.
- Skill in prioritizing and planning.
- Skill in public relations.
- Skill in interpersonal relations.
- Skill in oral and written communication.
SUPERVISORY CONTROLS
The Executive Director supervises and assigns work in terms of department goals and objectives. The supervisor reviews work through conferences, reports, and observation of department activities.
GUIDELINES
Guidelines include agency policies, federal state and local safety laws, regulations, codes and rules, including but not limited to, OSHA, Fire Department, USDA/Public Health, Medicaid, Alabama Department of Mental Health (DMH) guidelines/life and health standards, Department of Transportation (DOT) guidelines and Alabama Board of Nursing Standards and Practices. These guidelines are generally clear and specific but may require judgment, selection, and interpretation in application. This position develops department guidelines.
COMPLEXITY/SCOPE OF WORK
- The work consists of varied management, administrative, safety and risk management duties. Strict regulations and the need for attention to detail contributes to the complexity of the position.
- The purpose of this position is to direct the agency’s quality improvement operations and provide support for the agency’s safety and risk management functions. Successful performance contributes to delivery of effective services to individuals.
CONTACTS
- Contacts are typically with co-workers, other agency personnel, individuals served, representatives of other agencies, and members of the general public.
- Contacts are typically to exchange information, motivate persons, negotiate matters, resolve problems, and provide services.
PHYSICAL DEMANDS/ WORK ENVIRONMENT
- The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable an employee to perform essential job functions.
- The work is typically performed while sitting at a desk or table or while intermittently sitting, standing, or stooping. The employee must regularly lift and/or move up to 10 pounds, frequently lift and/or move up to 25 pounds, and occasionally lift and/or move over 25 pounds. Specific vision abilities required for this job include close vision, distant vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.
- The work is typically performed in an office.
SUPERVISORY AND MANAGEMENT RESPONSIBILITY
None.
MINIMUM QUALIFICATIONS
- Knowledge and level of competency commonly associated with the completion of a baccalaureate degree in a course of study related to the occupational field.
- Experience sufficient to thoroughly understand the diverse objectives and functions of the subunits in the division/department in order to direct and coordinate work within the division/department, usually interpreted to require three to five years of related experience.
- Meets Alabama Department of Mental Health QDDP qualifications.
- Possession of or ability to readily obtain Alabama Department of Mental Health Personal Outcome Measures/Personal Centered Training (POM/PCT) certification.
- Possession of a valid Driver’s License and good driving record.