Genesis Healthcare Director-Ctr Quality Assurance in Los Angeles, California

POSITION SUMMARY:

This position contributes to quality of care for patients by managing and coordinating all facets of the Center's Quality Assessment and Assurance Plan. This includes trending, tracking and analyzing quality assurance data, staff education and development, and monitoring and implementing proper infection control practices. The Quality Assurance Manager works collaboratively with all Department Heads and all staff to:

  • develop a performance improvement culture focused on quality patient care;

  • utilize data-driven performance improvement methods, e.g. data collection, data monitoring, providing oversight of performance to ensure sustainability of improvements;

  • coach staff in collaborative performance improvement methodology and technique through observation, on-the-job support, during PI/QA committee/subcommittee meetings;

  • foster a collaborative, learning environment across all departments and with all employees;

  • integrate performance improvement into all programs and processes across the Center; and,

  • ensure compliance with quality assurance state and federal regulations and Genesis Policy & Procedure.

As the Center Quality Assurance Manager, lead the Approach, Deployment, Learning and Integration of Quality Assurance Performance Improvement throughout the Center by engaging all employees and residents/families in an empathetic, encouraging and professional manner.

RESPONSIBILITIES/ACCOUNTABILITIES:

  1. Implement and continually improve an appropriate and effective performance improvement program consistent with the regulations in Colorado Department of Public Health and Environment regulations in Chapters II, §3.1.1 and V, Part 1

  2. Continuously evaluate the existing quality assurance program, identify areas for improvement, provide a report with timelines as to how the facility will implement appropriate changes to the current program to ensure quality care and services to the residents that will occur on a sustainable ongoing basis

  3. Ensure the ongoing development of a comprehensive program that includes:

  • a description of the types of cases, problems or risks to be reviewed and the criteria for identifying potential risks;

  • identification of personnel or committees responsible for coordinating quality management and the means of reporting to the Administrator;

  • a description of the method for systematically reporting information timely for dissemination to the appropriate designated individuals internally and externally;

  • a description of the method for investigating and analyzing the frequency and causes of individual problems and patterns of problems;

  • a description of the corrective action taken to address the problems;

  • a description of the method for the follow-up of corrective action to determine the effectiveness of such action;

  • a description of the method for coordinating all pertinent case, problem or risk review information with other applicable quality assurance and/or risk management activities;

  • documentation of required quality management activities, including cases, problems, or risks identified for review, findings of investigations and any actions taken to address problems or risks; and a schedule for plan implementation

  1. Prepare timely reports based upon licensure and regulatory compliance agencies.

  2. Develop and maintain written evaluations and plans/plan updates for the Center management team and regulatory agencies.

  3. Ensure that changes required by the regulatory agencies have been implemented timely and successfully.

  4. Develop and/or deliver educational programs revolving around: * Orientation to clinical standards for new and agency staff;

  • As mandated by OSHA, Genesis, Federal/State regulations;

  • All components of Quality Assurance, and programs to address the Quality Assurance process, plan and Regulatory guidelines.

  • Performance improvement cycle, root cause analysis, data monitoring and analysis, interviewing and investigation techniques, and other performance improvement methodologies and techniques.

  • Corrective action plans from completed audits, chart reviews, improvement activity/investigations. Ensure documentation of remediation and report to Department Head.

  • Interdepartmental in-service needs to promote behavior change to support appropriate standard of practice and Genesis HealthCare policies and procedures.

  1. In collaboration with CRC:
  • Monitor preparation, compliance and accuracy of MDS and monthly summaries/reports;

  • Provide and proctor the Center's MDS competency testing program for all licensed staff;

  • Educate staff, as necessary.

  1. In collaboration with Director of Nursing and Medical Director:
  • Analyze data from Center reports such as FQIP, Infection Control Report, COR, Quality Indicators, Quality Measures (MD), standing committees, CAR meeting, Incident and Accident reports, Pharmacy reports, etc. to determine if interventions are needed to improve outcomes

  • Track and review nosocomial infections on a systematic basis. Perform epidemiological investigation of all significant clusters of infection

  • Oversee and coordinate all staff and resident immunizations

  • Evaluate programs and effect changes as necessary to improve programs and assure compliance with regulatory requirements and patient care and safety standards.

  • Assist in the investigation of incidents, injuries, sentinel events, abuse and misappropriation of resident property. Summarize findings and file reports to appropriate staff and agencies.

  • Participate and assist in departmental studies and projects as assigned.

  • Monitor staff to ensure that residents and families receive the highest quality of service in a caring and compassionate atmosphere which recognizes the individual's rights and needs

  1. In collaboration with Division Quality Leader and Region Partner Team, ensure Center compliance with Quality Assurance/Performance Improvement program standards, healthcare quality and patient safety.

  2. Participate in all Performance Improvement/Quality Assurance meetings as described in the Center Quality Improvement Plan.

  3. Attend and participate in workshops, seminars, etc., to keep abreast of current changes in the health care field, as well as quality related topics.

  4. Maintain the confidentiality of all resident care information.

  5. Ensure resident rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right to wage a complaint, are well established and maintained at all times.

  6. Other duties as assigned

DCQA

SPECIFIC EDUCATIONAL/VOCATIONAL REQUIREMENTS: 1. Bachelor of Science in Nursing (BSN) from an accredited School of Nursing with current Registered Nurse licensure by the State Board of Nursing required. 2. Certified in Quality Assurance from an approved national accreditation/certification agency, e.g. CPHQ 3. 10 plus years of progressive management, healthcare and/or patient safety experience 4. Track record of successful application of data-driven Performance Improvement methodology to identify root cause and sustain outcomes. 5. Strong clinical skills, preferably in Gerontology. 6. Infection Control certification preferred. 7. Experience teaching adults preferred. EEO/AA, M/F, Vet, Disabled

Genesis HealthCare is an EO Employer- Veterans/Disabled and other protected categories