JOB SUMMARY: The Regional Director of Clinical Operations serves as a critical link in the identification and resolution of issues affecting hospice. This position integrates the quality management/performance improvement program with clinical and business goals and objectives. The Regional Director of Clinical Operations participates in gathering, trending and reporting data related to the oversight, planning and coordination of Quality management activities, including patient care reviews, compliance audits, concurrent and retrospective clinical record reviews for the interdisciplinary team. This position trends and analyzes utilization, outcome and quality data.

ESSENTIAL JOB FUNCTIONS

* Provides education and technical support to the program in developing, implementing and maintaining national quality improvement activities

* Collaborates with the QCC and QAPI Chairperson performance improvement taskforces and support the Executive Directors and DPCS in multiple locations

* Collaborates with leadership, staff, vendors and community in processes that continually improve the quality in all levels of care delivery

* Audits, monitors, tracks and trends risk, high volume problem-prone areas of hospice by the QAPI Corporate plan

* Proactive identification of issues and tracking of corrective action to minimize negative impact and maximize learning opportunities

* Collaborates with leadership in implementing regional/agency/organizational goals and objectives

* Develops and maintains relationships and effective communication with all levels of physicians and staff to facilitate problem identification and resolution

* Effectively communicates, both verbally and in writing, to assure that staff, leadership and QAPI Committees are informed of the status and issues related to the Performance Improvement Projects(PIP), utilization and risk management

* Works closely with locations, regional and national leadership to address patient care issues with a goal toward resolution while maintaining confidentiality, in addition to educating the locations to document the complaint resolution process and prepare reports for the QAPI Committees locally and for the corporate QAPI Committee

* In coordination with the Executive Director, assists with the completion of the annual program evaluation for submission to the QAPI Committee, Governing Body and Regional VPO and VPCO

* Determine program educational needs in accordance with CoP and accreditation standards via audits.

* Participates in regional QCC education and program development

* Audits medical records in collaboration with location QAPI Committees and the corporate QAPI Committee to ensure the integrity of the medical records is sustained

* Directs, monitors and ensures QCC staff initial, annual and ongoing orientation and education is completed by all staff members in accordance with hospice, CoP and accreditation standards

* Provides direction and coordination of quality improvement principles and methodologies according to the National QAPI Plan

* Supports agency activities related to IDT clinical record review andchart audits for data collection/aggregation and reporting the location

* Compiles, aggregates and assists with trending of quality and clinical operations data in the following areas: patient care, safety, risk management, chart/documentation audits, infection control, outcomes, public reporting, hospice compare and customer satisfaction

* Participates in continual survey readiness and federal audits for locations and the national office

* Collaborates with the Informatics Nurse to manage and maintain accurate reliable data that complies with regulations, accreditation and agency standards

* Maintains an expert knowledge level in the EMR to facilitate the SuperUser role in training and problem solving for multiple locations

* Hires, evaluates and terminates organization personnel

* Conducts annual evaluations of direct reports, or more frequently if needed

* Develop, implement and evaluate the orientation program for new organization personnel

Performs any other duties as assigned by the Regional VP of Clinical Operations

Qualifications

REQUIRED EDUCATION & EXPERIENCE:

* Must be a Registered Nurse

* Must have a minimum five (5) years' experience as a nurse, hospice nursing strongly preferred

* Must be at least 18 years of age

REQUIRED KNOWLEDGE, SKILLS & ABILITIES:

* Must have knowledge of federal, state and accreditation standards applicable to hospice

* Must have knowledge of governmental and other regulatory standards, requirements and guidelines related to quality improvement

* Must have strong working knowledge of ongoing monitoring techniques (including criteria development and statistical analysis); total quality management principles, tools and techniques

* Must have the ability to effectively communicate, negotiate and lead

OTHER REQUIREMENTS:

* Must be flexible in work schedule

WORK ENVIRONMENT:

* Must comply with company policies, procedures and processes in addition to Hospice rules and regulations

* Must comply with harassment and discrimination policies

* Must be willing and able to work alone and in a team environment

* Must be able to travel short and long distances as required, up to 50% of the time

* Must be flexible in work hours to accommodate program needs

* Must be willing to submit to a criminal background check prior to hire and annually thereafter

* PHYSICAL ENVIRONMENT

* Must be able to see with or without accommodations

* Must be able to work on a computer for prolonged periods

* Must be able to stand and sit for long periods

* Must be willing to participate in a drug/alcohol screen prior to hire, if involved in a work- related automobile accident or id reasonable suspicion is reported

* Will be working with standard office machines such as computers, printers, copiers, fax machines, telephones, etc.