Quality Improvement Manager na Everstand

POSITION SUMMARY:

Reporting directly to the Senior Director of Center of Excellence, Quality Improvement and Training, the Quality Improvement (QI) Manager is responsible for the day-to-day operations of the QI department, with primary oversight of stakeholder surveys, chart audits, performance (outcome) measurement and management targets, and external reporting.  The QI team also oversees Everstand’s Electronic Health Record (EHR) software, and the QI manager ensures that daily support tickets are being addressed, larger system upgrades are planned and executed, and training materials are kept up to date.

The position requires experience with data analytics, maintaining project plans and timelines, strong coordination and communication skills, and the ability to effectively translate audit and survey results into performance improvement plans. 

Essential Functions:

• Model and act in accordance with Everstand’s core values: safety, empathy, relationships, and impact.
• Honor differences, acknowledge uniqueness, and amplify all voices. Participate in training and group experiences that explore Equity, Diversity, and Inclusion (EDI) topics. Model the use of inclusive language.
• Demonstrate and practice Everstand’s leadership mindset, “Choose kindness. Solve problems and learn together. Make it happen.”
  • Attain Collaborative Problem Solving® Tier 2 certification and serve as a trainer and mentor of this practice for others.
• Lead screening, interview, hiring, and onboarding, and ongoing training for the Quality Improvement department.
• Update assigned key performance indicators (KPI's) and report them to the Senior Director of Center of Excellence, Quality Improvement and Training and wider BCC leadership team.
• Develop the schedule and monitor the completion of all fiscal year audits and surveys to meet licensure and accreditation standards. Confirm audit templates in use are up to date and are guiding examination of any areas previously that may have lagged below standard.
• Ensure the survey administration components are completed throughout the year.
• Produce key findings of audit and survey results for review by the Director of QI and Training.
• Support all committee work associated with the Risk Management, Performance Measurement, and Management, and Corporate Compliance Plans of the organization.
• Lead and/or assign survey results debrief meetings with the program and departmental leaders.
• Ensure QI project timelines are coded into Asana and that updates to the project statuses are being made in a timely fashion.
• Oversees the QI team’s responsibility for all EHR system administration, general maintenance, and upgrades to the software. Including EHR rollouts and coordination efforts with the EHR vendor including end-user training plans/follow-up support.
• Oversees EHR super users resource including the recruitment and onboarding of new members as well as the associated operational implementation across agency locations.
• Ensure QI inbox inquiries and EHR help desk tickets are addressed in an efficient and timely manner.
• Ensure policy updates across Everstand are captured in the relevant policy and procedure manual. Oversee the annual process of updates to the p&p manuals culminating in the Board of Director review and approval.
• Communicate policy changes to Everstand’s training team and partner with them on how Everstand will educate its workforce on those changes.
• Interpret requests for data into search criteria and create visual displays that meet the needs of the initial request. Delegate research and analysis components as needed.
• Ensure the QI team is running routine and scheduled reports and distributing those to internal and external stakeholders on time.
• Monitor compliance of applicable laws, regulations, evidence-based practices, and accreditations. This includes but is not limited to Maryland, District of Columbia, Pennsylvania, and West Virginia regulatory bodies to ensure that audit templates and reports support those standards.
• Code performance improvement plans into Asana so key deadlines are visible and trackable.
• Ensure the formal concerns/discovery process is administered to all critical incidents/policy violations deemed appropriate. Oversight would focus on providing guidance to ensure investigations are moving forward toward completion as well as being properly documented in Asana
• Partner with the Training Manager to ensure training materials are accurate and kept up to date
• Update assigned elements and goals of the QI department’s strategic plan.
• Partner with the Senior Director of Center of Excellence, QI & Training to nurture a strong quality culture at BCC that learns from mistakes and strives for incremental performance improvement.
• Ensure the privacy of personal information and records is maintained through audits and training programs. Partner with other senior leaders to meet HIPAA regulations and standards.
• Partner with Program and Facilities team to ensure proper oversight of the facility inspection, Orion driving system, and walkthrough process

Non-Essential Functions:

• Participation in Everstand’s program development workgroups
• Serve as POC for certain external stakeholders when assigned.
• Provide state licensing and other regulatory bodies access to Cx360 via a guided review during audits of charts and records.
• Creating learning modules within Everstand’s learning management system
• Conducting training sessions for employees as needed on a variety of topics (e.g. QI, EHR)

Competencies:

• Accountability for Others
• Accurate Listening
• Attention to Detail
• Attitude towards Honesty
• Delegate tasks to others with follow up
• Handling Stress
• Leading others through periods of cultural and/or operational change
• Meeting Standards
• Organized Workplace
• Persistence
• Personal Accountability
• Problem Solving Ability with focus on ability to provide tangible and workable solutions
• Self-Management
• Read and comprehend regulation and licensing requirements and translate those to business rules and workflows within a business unit and within a software program
• Interview and visually document organizational workflows with chronological and documentation requirements noted.
• Manipulate and reformat data as needed for migration
• Interpret a request for data into search criteria, and then ultimately craft the selected data into a visual display that meets the needs of the initial data request.
• Knowledge of HIPAA laws and how they apply to access to data within a software system / be able to correctly set the security permissions within software.

Supervisory Responsibility

This position directly supervises 6 positions:

• QI Coordinator (Domestic focus)-2
• Caminos Shelter QI Coordinator (WV)
• Caminos Shelter QI Coordinator (PA)
• Caminos Shelter QI Coordinator (MD)
• Caminos HS/PRS QI Coordinator

Work Environment:

This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, desk phones, smart phone and tablet devices, scanners, photocopiers, filing cabinets and fax machines.

In the nature of being at a residential and school living environment there may be times you experience conditions in which challenging behavior can be exhibited from program participants.  This may include but is not limited to, physical agitation, physical violence and/or emotional outbursts.

Physical Demands:

While performing the duties of this job, the employee is frequently required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; use a ladder; balance; stoop, kneel, crouch or crawl; talk or hear; and smell. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.

Position Type/Expected Hours of Work:

This is a full-time position. Days and hours of work are Monday through Friday, 8:30 a.m. to 5 p.m.  This position may require work outside normal business hours. This position is eligible to participate in Everstand’s flex schedule policy.  This position is considered non-essential during inclement weather.   

Travel

Travel is required on at least a weekly basis.  A company vehicle will be provided as needed. 

Required Education and Experience

• Bachelor’s degree with 5 years’ experience or Master’s Degree with 2 years’ experience from an accredited university
• Minimum of 3 years’ experience executing quality improvement/assurance job tasks
• A minimum of 2 years administering a database (e.g. SQL or equivalent) with responsibility for data import & mapping, data cleanup, data export, and reporting.
• Minimum of 2 years’ experience as an administrator of an electronic health record software system.
• Minimum of 2 years of using Microsoft Excels’ graphing, pivot table, and other advanced data visualization and data manipulation functions.
• Minimum of 1 year of supervisory experience.

Preferred Education and Experience

• 1 year project management experience working with differing timelines and multiple simultaneous projects occurring.
• 1-year experience of visually mapping complex workflows (e.g. using Microsoft Visio or equivalent).
• Healthcare industry experience, especially behavioral health, preferred.
• 2 or more years of supervisory experience.

Additional Eligibility Qualifications

• Must be able to self-manage and prioritize daily schedules, work effectively in a collaborative style with internal and external stakeholders, team members, managers and executives. 
• Strong ability to pro-actively identify and mitigate project risks, escalate and track issues to resolution, and creatively problem solve to find alternative solutions.
• Able to understand the interrelationships of databases, data files.
• Ability to read/understand vendor training materials.
• Excellent writing skills and experience in producing training-related materials. Able to effectively communicate with individuals at various levels of computer skill.
• Ability to lead meetings, prioritize, resolve conflicts, maintain issues lists and manage a project plan required.
• Strong communication and follow-up skills required.
• Knowledge of Maryland, Pennsylvania and West Virginia residential care regulatory requirements a plus.
• Proven ability to manage multiple projects, priorities, meet deadlines, multi-task, and think creatively.
• Solid Windows 10 computer proficiency.
• Advanced knowledge of Microsoft Word is required (e.g. mail merge, creating a live table of contents).
• Proficiency in Microsoft Outlook and PowerPoint.
• Ability to keep an electronic calendar (Outlook) and task list (com) is required.

• Ability to obtain and maintain certification in CPR/First Aid.

• Ability to demonstrate the possession of a valid driver’s license prior to employment and ability to maintain the license and operate a motor vehicle thereafter.

• Ability to pass CPS/UII background check both prior to employment and per the schedule outlined by HR thereafter.
• Ability to pass a Tuberculosis Test both prior to employment and per the schedule outlined by HR thereafter.
• Ability to pass a work-readiness physical performed by a certified medical professional both prior to employment and per the schedule outlined by HR thereafter.
• Ability to pass a Federal and State Fingerprinting Background Check both prior to employment and per the schedule outlined by HR thereafter.
• Ability to pass a drug screen via urinalysis both prior to employment and randomly thereafter.

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Employee signature below constitutes employee's understanding of the requirements, essential functions and duties of the position.

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