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Director of Quality & Performance Improvement

Tenet Health Type Full time Posted 7/22/2014
Salary - n/a - Starts 9/21/2014
MA - Massachusetts (All) Referral - n/a -    
Job Details:

MetroWest HomeCare & Hospice

                                                Touching lives…every day

MetroWest HomeCare & Hospice, a division of MetroWest Medical Center and affiliated with St. Vincent Hospital, is the leading choice for home healthcare in 63 communities in MetroWest and Central Massachusetts. Having been awarded HomeCare Elite for three years running, we take pride in the services we provide for our patients. This is an excellent opportunity to join a dynamic and growth oriented team that strives for the best, always.

TITLE: Director of Quality & Performance Improvement

REPORTS TO:   Executive Director / SVP


1.      A minimum of a Bachelor’s degree with advanced training a plus

2.      Strong background in homecare (hospice a plus); at least 5 years homecare experience with 2-3 years management experience

3.      Strong commitment to quality and patient safety

4.      Ability to analyze and interpret data

5.      Demonstrated organizational skills, self directed and independent in fulfilling role obligation

6.      Advanced computer skills in a windows environment including Microsoft Office Suite

POSITION SUMMARY: Responsible for the direction and management of all quality & performance improvement activities for both homecare and hospice. Performance improvement activities include, but are not limited to: quality, regulatory, documentation compliance and education. Direct reports include: Clinical Educator and Clinical Special Projects Coordinator. Oversight of OASIS Coordinator, Certified Coder(s), Clinical Documentation Coordinator


  1. Manage and oversee all performance/quality improvement and education activities for both home care and hospice.
  2. Manages and implements a comprehensive performance and quality improvement plan and program that identify a process to evaluate its performance in all functional areas.

3.      Maintains expertise with Joint Commission and DPH standards and survey processes. Overall responsibility for ensuring compliance with Joint Commission preparation, certification under the Medicare Conditions of Participation and responses to any state/federal surveys.

  1. Manages all quality data reporting including but not limited to: CASPER, Home Health Compare, HHCAHPs, Adverse Events Reports, and OASIS error reports. Makes recommendations to improve procedures.
  2. Monitor and analyze data on a monthly basis and recommend improvements to the management team based on data analysis. Produce Monthly Dashboard for Quality & Performance Reporting.
  3. In collaboration with the Director of Hospice, coordinates and facilitates all Hospice QAPI activities including but not limited to:

o   Provides guidance and make recommendations to the governing body on the development of the Hospice QAPI Plan and ensures that QAPI Program meets all regulatory requirements.

o   Ensures the collection of accurate and dependable data

o   Aggregates, trends and analyzes data using appropriate statistical techniques

o   Identifies opportunities for improvement through aggregation and analysis of data

o   Engages appropriate staff participation in improvement activities

o   Reports significant findings to appropriate constituencies

o   Monitors changes for sustained improvement

o   Oversees planning and implementation of Performance Improvement Projects

  1. Manage the response to all fiscal intermediary and government requests for medical records and additional documentation. Manage medical review appeal process.
  2. Direct the development of orientation and staff education programs for all levels of staff and management.
  3. Collaborate with the Clinical Education & Documentation Manager to:

o    Evaluate the need for educational programs to improve the level of staff performance and quality;

o    Ensure up to date education and assist with employee performance improvement plans.

  1. Leads or participates on related committees including but not limited to: Chair, Quality & Safety Council, Chair, Professional Advisory Committee, Co-Chair, Hospice QAPI, Co-Chair RISC, Orientation & Education Workgroups, and IT Super User/Release Team.
  2. Participate at the Hospital level for meetings related to Performance Improvement: Quality & Safety, Infection Control, and Joint Commission.
  3. Participate in State level (HCA MA) meetings related to Performance Improvement
  4. Perform quarterly clinical records audits and clinical documentation review/coding and additional clinical record review as appropriate and necessary.
  5. Maintains a high level of knowledge relative to new regulatory issues including Medicare PPS, COPs, and OASIS. Has thorough knowledge of regulatory guidelines including those from CMS, DPH and fiscal intermediaries.
  6. Fosters a culture of quality and safety based upon solid performance improvement initiatives.
  7. Ensures that clinical care is of the highest level and supported by evidence-based research.
  8. Assures compliance with all local, state and federal laws.
  9. All other responsibilities as assigned.

WORKING CONDITIONS: Office environment, constant use of computer and telephone.

The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.

MetroWest Medical Center offers a competitive rate of pay and a comprehensive benefits package.

Please visit our website for additional information at