Quality Assurance Process Improvement Manager

Important Recruitment Information for this vacancy

• Job Posting closes: Open until Filled
• Required documents uploaded by: All required documents listed below must be attached to your application within 2 days of applying for your application to be considered complete.

Agency Information:

Kansas Department for Aging and Disability Services

Protecting Kansans, Promoting Recovery and Supporting Self Sufficiency

https://www.kdads.ks.gov/

About the Position

Who can apply: Anyone

Classified/Unclassified Service: Unclassified

Full-Time/Part-Time: Full-Time

Regular/Temporary: Regular

Work Schedule: M-F

Eligible to Receive Benefits: Yes

Veterans' Preference Eligible: Yes

Disability Preference Eligible: Yes

Search Keywords: Quality Assurance Process Improvement Manager

Compensation: Up to a maximum salary of $68,000.00 annually.

• Salary can vary depending upon education, experience, or qualifications.

Employment Benefits

Comprehensive medical, mental, dental, vision, and additional coverage

Sick & Vacation leave

Work-Life Balance programs: parental leave, military leave, jury leave, funeral leave

Paid State Holidays (designated by the Governor annually)

Fitness Centers in select locations

Employee discounts with the STAR Program

Retirement and deferred compensation programs

Visit the Employee Benefits page for more information…

Position Summary & Responsibilities

Position Summary:

The incumbent of this position is responsible for developing, implementing and monitoring the ongoing performance improvement process for all of areas of the hospital. This position provides oversight for data, statistical analyses and outcome reporting of critical performance improvement activities related to patient care, accreditation, safety, and clinical treatment. The incumbent is a member of the accreditation team that conducts internal audits, reviews and surveys to ensure compliance with all local, State and Federal regulatory standards. Training other staff in the performance improvement process and ensuring a firm understanding of the process & outcomes is another core duty.

The incumbent of this position has authorized access or the potential of incidental exposure to Protected Health Information (PHI) under the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule. PHI must be treated in accordance with the provisions of the HIPAA Privacy Regulation including the requirements for safeguarding, releasing and recording the release of such information. The incumbent will be trained in the provision of the HIPAA Privacy Regulations as they relate to the duties of the position.

Job Responsibilities may include but are not limited to the following:

Performance Improvement (PI): Works with hospital leadership and the PI Council to develop and determine recommendations for performance improvement projects. Prepares and maintains the Performance Improvement Plan for the hospital. Assists the Executive Committee in setting performance improvement priorities and goals. Identifies resources needed to support performance improvement.

Assist staff in understanding and executing their roles in the improvement process. Motivates individuals to pursue both personal improvement activities and group performance improvement projects. Assists service managers in establishing formal targets and goals. Provides expertise to services/programs/committees in clearly articulating improvement goals, designing data collection tools, developing reliable data collection methods, analyzing and presenting data, and conducting self-evaluations. Monitors implementation of performance improvement throughout the hospital. Responds to other managers’ requests for information. Monitors current trends in order to effectively guide the hospital’s PI program. Develop forms to use to ensure a free flow of information. Maintains records of performance improvement projects throughout the hospital.

Ensures compliance with accreditation requirements related to the Performance Improvement Plan and performance improvement activities.

Develop performance improvement training including performance improvement, orientation, and annual training. Educates staff regarding performance improvement through written communications and computer-based training. Recommends resources (audio- and videoconferences, books, computer-based training, videotapes, and DVDs) to supplement other training. Facilitates PI teams as needed and attends departmental meetings upon request to discuss PI. Schedules work to include all shifts and days when necessary to assist staff with PI needs. Facilitates teams conducting failure mode and effects analyses (FEMA).

Accreditation: Directs both Hospital’s Accreditation/Certification Program relative to JCAHO and CMS in order to assure quality and safety of service to patients and to prevent loss of revenue to the institutions. Reviews JCAHO and CMS reports and, in collaboration with executive staff, develops corrective action plans to bring the organizations into compliance. Maintains a working knowledge of relevant standards, regulations and laws. Disseminates information, trains staff and monitors ongoing compliance by continuously reviewing service meetings minutes and Performance Improvement reports and conducting internal reviews as deemed appropriate. Chair the Accreditation Committee. Incumbent is also a member of the following standing committees: Executive Committee, Citizens Advisory Board and Performance Improvement Board.

Research, interpret and translate regulatory and licensing requirements for rules and regulations applicable to the operations of the hospitals. Review literature to identify changes in standards, rules and regulations. Communicate changes regularly to hospital leadership. In collaboration with others, review and revise hospital policies and procedures to ensure compliance with application standards, rules and regulations. The regulatory organizations include but are not limited to the Kansa Department of Health & Environment (KDHE), Centers for Medicare and Medicaid Services (CMS) and the Join Commission (TJC).

Provides education on CMS/KDHE regulations and TJC standards regarding regulatory organization requirements to the Leadership Development Team. Continually work with leadership staff to audit departments compliance to standards and regulations for regulatory organizations. Provide education regarding regulatory organization requirements to staff as requested.

Provide follow up education and assistance to staff related to findings and plans of correction. Maintain survey readiness by updating relevant forms and procedures throughout hospital changes. During actual surveys, assist in ensuring that all materials are provided to the survey teams as required or requested, and assist leadership throughout the survey process (including post-survey activities) Provide mock survey and trace activities analysis and when requested by leadership. Submits annual license application and data information to various organizations to ensure compliance with licensing regulations.

Data Analysis: Collects, organizes, analyzes, and interprets hospital-wide data. Uses software to flow-chart processes and display data in formats that enhance the value of the data (e.g., pie charts, bar charts, line graphs, control charts & trend lines). Performs basic statistical tests such as chi-square, correlation and analysis of variance. Reports the results of analyses and summarizes findings in a concise, clear manner. Serves as a consultant for data analysis to teams conducting performance improvement projects.

Manages Data Submission and Report Distribution for NRI Measures: Interprets participation requirements for NASMHPD Research Institute (NRI) performance measures, The Joint Commission (TJC) Core Measures Set, and Centers for Medicaid and Medicare (CMS) mandatory reporting; and answers questions related to data submission. Monitors integrity of data submitted. Distributes performance measurement system reports and assists staff in analyzing data. Ensures compliance with requirements.

Will ensure that IDT Treatment Team Meetings occur as regulated. Attend Treatment Team/IDT meetings as directed. Is responsible for auditing treatment plans for accuracy and individual patient centered interventions.

Completes special projects and performs other duties as assigned including but not limited to ensuring the agency is adequately staffed during and immediately following natural and/or manmade disasters, infectious disease outbreaks, and/or acts of terrorism. Assists other employees in the work unit in accomplishing assignments as necessary.

Qualifications

Minimum Requirements:

• At least one year in planning, organizing and directing the work of a department, program or agency.
• Must have a solid understanding of QA principles and be able to recognize and resolve opportunities to improve as well as resolve conflicts between operational practices and guidance.
• Innovative, self-starter with excellent follow through.
• Unrestricted Driver’s License

Preferred Qualifications:

• RN; Bachelor’s Degree in nursing with four years of clinical experience and/or Bachelors in related field.
• Proficient knowledge of Microsoft Office Products including Excel, Outlook, PowerPoint, and SQL. Experience working in an inpatient setting; experience in working with accrediting bodies (e.g., TJC, CARF, KDHE, CMS); and experience in statistical analyses is preferred.

Post-Offer, Pre-employment Requirements:

• Must be able to pass a background check prior to employment.

Recruiter Contact Information

KDADS – Human Resources Recruiter

503 S. Kansas Ave

Topeka, KS 66603

Phone: 785-296-0463

Fax: 785-368-6688

Email: KDADS.APPLY@ks.gov

Job Application Process

First Sign in or register as a New User.

Complete or update your contact information on the Careers> My Contact Information page. *This information is included on all your job applications.

Upload required documents listed below for the Careers> My Job Applications page. *This information is included on all your job applications.

Start your draft job application, upload other required documents, and Submit when it is complete.

Manage your draft and submitted applications on the Careers> My Job Applications page.

Check your email and My Job Notifications for written communications from the Recruiter.

Email – sent to the Preferred email on the My Contact Information page

Notifications – view the Careers> My Job Notifications page

Helpful Resources at jobs.ks.gov: “How to Apply for a Job – Instructions” and “How to Search for a Job – Instructions"

Required Documents for this Application to be Complete

Upload these on the Careers - My Job Applications page

• DD214 (if you are claiming Veteran’s Preference)

Upload these on the Attachments step in your Job Application

• Resume
• Cover Letter

Helpful Resources at jobs.ks.gov: “How, What, & Where do I Upload Documents”

Kansas Tax Clearance Certificate: A valid Kansas Tax Clearance Certificate is a condition of employment for all employees of the State of Kansas. Applicants (including non-residents) who receive a formal job offer for a State job, are required to obtain a valid Tax Clearance within ten (10) days of the job offer. A Tax Clearance can be obtained through the Kansas Department of Revenue who reviews individual accounts for compliance with Kansas Tax Law.

If you have a missing tax return(s) or you owe taxes to the State of Kansas, please know that the Kansas Department of Revenue will work with you. The Kansas Department of Revenue can set you up on a payment plan to receive a Tax Clearance so you can get a job working for the State of Kansas. The Kansas Department of Revenue can be contacted at 785-296-3199. Kansas Department of Revenue - Tax Clearance Frequently Asked Questions

How to Claim Veterans Preference

Veterans' Preference Eligible (VPE): Former military personnel or their spouse that have been verified as a "veteran"; under K.S.A. 73-201 will receive an interview if they meet the minimum competency factors of the position. The veterans' preference laws do not guarantee the veteran a job. Positions are filled with the best qualified candidate as determine by the hiring manager.

Learn more about claiming Veteran’s Preference

How to Claim Disability Hiring Preference

Applicants that have physical, cognitive and/or mental disabilities may claim an employment preference when applying for positions. If they are qualified to meet the performance standards of the position, with or without a reasonable accommodation, they will receive an interview for the position. The preference does not guarantee an applicant the job, as positions are filled with the best qualified candidate as determined by the hiring manager.

Learn more about claiming Disability Hiring Preference

PLEASE NOTE: The documentation verifying a person's eligibility for use of this preference should not be sent along with other application materials to the hiring agency but should be sent directly to OPS. These documents should be scanned and emailed to Gustavo.Victoriano@ks.gov, or can be mailed/delivered in person to:

ATTN: Disability Hiring Preference Coordinator
Office of Personnel Services
Docking State Office Building
915 SW Harrison Ave, Suite 260
Topeka, KS 66612

Equal Employment Opportunity

The State of Kansas is an Equal Opportunity Employer. All qualified persons will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, political affiliation, disability or any other factor unrelated to the essential functions of the job.

If you wish to identify yourself as a qualified person with a disability under the Americans with Disabilities Act and would like to request an accommodation, please address the request to the agency recruiter.