Quality Improvement Director

ESSENTIAL FUNCTIONS:  

• 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 deficiencies.  
• Complete necessary forms, reports, etc., and submit to the Administrator as required.  
• Schedule QAPI Committee meetings at least quarterly and notify members.
• 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.