Quality Improvement Director

Responsible for ensuring multidisciplinary quality assurance and performance improvement (QAPI) activities within the facility that are in accordance with established requirements.  

Establish and implement effective, comprehensive, data driven QAPI programs that focus on systems of care including indicators of outcomes of care, quality of life and resident and staff satisfaction.  

Develop the five elements of a QAPI program and coordinate the required activities.  

Evaluate programs and implement changes as necessary to improve programs and assure compliance with regulatory requirements.  

Communicate revised plans and changes to facility management and governing body.  

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

Complete necessary forms, reports, etc., and submit to the Administrator as required.  

Schedule QAPI Committee meetings at least quarterly and notify members of such meetings.  

Maintain a reference library of written QAPI material, laws, etc., necessary for complying with current standards and regulations.   

Provide reports/recommendations to the Administrator as necessary/required concerning the operation of the QAPI program.  

Assume the authority, responsibility and accountability of directing the QAPI department.  

Review the facility’s quality measures and survey reports to assist in identifying potential problem areas. Make reports to committee as necessary.  

Proactively identify areas of concern for noncompliance and develop a plan of action, measurement, training and follow-up; develop reports to document these initiatives.   

Participate in facility surveys as necessary or as directed.  

Serve as chairperson of the QAPI Committee.  

Meet with the QAPI Committee monthly to review all assessment tools designed, all data collection reports and all activities carried out by departments, services or committees that have a direct impact on resident care and safety.  

Serve on various committees of the facility (i.e., pharmacy, safety, resident care, policy advisory, etc.) as deemed appropriate and as appointed by the Administrator.  

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

Implement recommendations from the QAPI Committee as they relate to the quality assurance program.  

Attend and participate in annual facility in-service training programs (e.g., Occupational Safety and Health Administration (OSHA), tuberculosis (TB), Health Insurance Portability and Accountability Act (HIPAA), abuse prevention, safety, infection prevention and control, etc.).  

Sufficient previous experience in clinical health care including direct experience in quality assurance and performance improvement. 

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

Must be a supportive team member, contribute to and be an example of team work and team concept.  

Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel and the general public.  

Must be knowledgeable of quality assurance and performance improvement procedures.  

Must possess leadership and supervisory ability and the willingness to work harmoniously with other personnel.  

Must possess the ability to plan, organize, develop, implement and interpret the goals, objectives, policies, procedures, etc., of the QAPI program.  

Must have patience, tact, a cheerful disposition and enthusiasm as well as the willingness to handle difficult residents and staff.  

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