Position Summary:

Person in this position will serve as a subject matter expert to WestCare's leadership team, especially regional management teams in the design of quality improvement activities, licensing regulations, and accreditation. This person will directly monitor the required accreditation functions while preparing WestCare's regions for an accreditation survey. Essential Job Functions include those listed below. Other duties may be assigned as needed.

Essential Job Functions:

Provide education and training on Quality Improvement theories, strategies, and tools for staff on implementing program improvements. Assure program compliance with applicable contract, local, state, federal and accreditation requirements. Assist with Corrective Action or QI plans required for external audits. Implement, adhere to, and monitor licensing and CARF (or other accrediting body) standards and agency policies and procedures. Implement and direct appropriate use of statistical process controls, used to manage data-based decision-making. Develop tools, forms, and processes to ensure compliance with accreditation and internal standards and practices. Embrace and embody the mission, vision, guiding principles, clinical vision, and goals of WestCare Foundation. Assists other WestCare staff as needed in a collaborative manner to promote cooperation and portray a professional image to the community. Responsible for improvement of programs designs by assuring the implementation of Performance Improvement (PI) standards, evaluations, and outcome measures. Review and aggregate clinical data and outcomes to identify clinical trends and provide analysis to the Vice President. Assist programs that need Performance Improvement by developing Pl methodology plan. Create Executive Summary narratives of Pl projects with metric analysis. Perform Root Cause Analysis on critical incidents. Collaborates with the WestCare Evaluation and Quality Department to envision, develop, and implement the GCFL continuous quality improvement program.

 

 

 

 

 

 

 

 

 

Conducts chart reviews using a standardized form and enters data into the appropriate database. Assists the WestCare Evaluation and Quality Department with biannual Performance Improvement Reports Participate in meetings and attend trainings as required and requested. Completes all orientation and mandated training activities, including E-Learning Courses, within required timeframes, and in accordance with the criteria established for this position. Other relevant duties as assigned.