JOB TITLE: QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT ADMINISTRATOR

JOB CODE: 43388

DEFINITION: This is professional and administrative work directing an integrated quality assurance and performance improvement (QAPI) program for an agency direct care health delivery system.

An employee in this job directs the development, implementation, evaluation, modification, and enhancement of all aspects of the QAPI program for all health care facilities within an agency. Work involves developing programmatic governance including policies, goals, and measures; advising agency leadership on QAPI program direction; developing strategic and long-term plans to improve program quality and performance; and coordinating with interdisciplinary leadership to identify and promote opportunities for program enhancement. Work includes establishing reporting mechanisms and developing metrics to strengthen data integrity; and ensuring all regulations, policies, procedures, and practices are applied and interpreted consistently throughout all facilities. Supervision is exercised over professional administrative staff who carry out the QAPI program. Work is performed with a high degree of independence and is reviewed by an administrative supervisor for effectiveness through conferences, reports, and program accomplishments.

EXAMPLES OF WORK: (NOTE: The examples of work are representative of the work, but every position classified to this job may not perform all examples of work listed. Conversely, this is not an all-inclusive list of work examples.)

• Develops, implements, and evaluates quality management strategies for a statewide direct care health delivery system.

• Develops and implements a QAPI program and corresponding internal controls that incorporate quality assurance principles for facility services provided.

• Develops and implements quality and performance improvement plans and supports facilities in reaching plan goals.

• Collects and analyzes data to establish department quality and performance improvement goals; and to evaluate the effectiveness of policies, standards, practices, and staffing in meeting those goals.

• Establishes qualitative and quantitative measures to track performance for department facilities and analyzes measures used to identify performance issues and potential problem areas.

• Develops, implements, monitors, and modifies policies to ensure adherence to internal standards, best practices, and regulatory compliance.

• Identifies and facilitates continuous improvements to clinical care, business processes, and customer service through observation, coordination with internal partners, and related policy change recommendations.

• Develops, recommends, and standardizes best practices to improve performance, quality of care, and services across department facilities.

• Oversees the preparation of facilities for independent third-party surveys, external audits, and investigations.

• Responds to external facility audits and provides data to auditing organizations to demonstrate regulatory compliance and adherence to established standards.

• Recommends and implements corrective action plans to address findings and deficiencies identified through audits.

• Develops and implements plans to prevent and address deficiencies in compliance, safety, and facility performance.

• Researches federal and state statutes and regulations, clinical advances, and best practices in health care delivery.

• Promotes an environment of QAPI-related education, collaboration, and innovation.

• Directs staff performance improvement education and development.

• Performs the full range of supervisory duties.

• The employee in this job may participate in the performance of subordinates’ work consistent with operational and organizational requirements.

• Performs related work as required.

ENTRY LEVEL KNOWLEDGES, SKILLS, AND ABILITIES:

• Knowledge of the principles, practices, and methods of program planning, and organization in a health care facility.

• Knowledge of the principles and practices of health care administration.

• Knowledge of the laws, standards, and regulations governing the administration of health care facilities.

• Knowledge of Medicare, Medicaid, and other national standards of individual healthcare and treatment resources.

• Knowledge of the methods and techniques used in data collection, analysis, and reporting.

• Knowledge of the use and functionality of Microsoft Office Suite software.

• Ability to analyze and interpret health care data.

• Ability to analyze and apply clinical and non-clinical health care practices.

• Ability to read and interpret policies, procedures, and regulations.

• Ability to establish and maintain effective working relationships.

• Ability to communicate effectively orally.

• Ability to communicate effectively in writing.

MINIMUM EXPERIENCE AND TRAINING: (NOTE: Based on the Entry Level Knowledges, Skills, and Abilities)

• Five years of professional experience in an administrative, consultative, quality assurance, or direct care capacity in a health care setting and a bachelor’s degree;

or

• An equivalent combination of experience and training.

SPECIAL REQUIREMENTS:

• The position at the Department of Military and Veteran Affairs requires possession of an active Nursing Home Administrator license as issued by the Pennsylvania State Board of Examiners of Nursing Home Administrators.