The primary function of the Performance Improvement Specialist is to support and facilitate quality assessment and performance improvement (QAPI) activities for the local hospice branch (also referred to as hospice program). The QAPI Program is an on-going, data driven, organization-wide program involving data collection, analysis, and collaborative development of performance improvement initiatives.
Performs quality monitoring activities (tracking, trending, and analysis) including, but not limited
- Hospice Quality Reporting Program (HQRP): data collection and analysis of data associated with HQRP components, including but not limited to: Consumer Assessment of Healthcare Providers and Systems survey (CAHPS), claims-based measures, Hospice Item Set and any future measures.
- Care Compare: data collection, tracking, and benchmarking HQRP scores against competitors.
- CAHPS analysis process (optional process): data collection, analysis, and reporting.
- CAHPS survey: Identify negative comments/responses and initiate service comments as appropriate.
- QAPI dashboard: drill down, analyze and report data.
- Service Comments: includes monitoring timely resolution, reassignment of pending service comments, communication of trends to program management, and ensure service comment log is current.
- Infection Control Reporting: data maintenance and analysis.
- Incident Reporting: data maintenance and analysis, submission of documents for incidents identified as serious adverse events, completion of 3500A for home medical equipment-related incidents.
- Root Cause Analysis (RCA): co-facilitate RCA meeting with program management, ensure required documents are completed, document meeting on appropriate templates, submission of documents to required email distribution group, monitor effectiveness of corrective action plan and report outcomes to program leadership.
- Revenue Analysis and Tracking: analyze and trend Unaccrued Revenue using report provided by Revenue Cycle Management and report findings to program management.
- Hospice Aide (HA) In-service hours: obtain training completion report and report compliance with regulation requirement to program management.
- Annual Update HIPAA/OSHA: Obtain training completion report for annual updates and report compliance to senior management.
- Physician satisfaction surveys (as required by the program): data collection, analysis, and reporting.
- Revocation and discharge monitoring (as required by the program): data collection, analysis, and reporting.
- Collect and analyze quality indicator data/key performance indicators and collaborate with the senior management team to identify priorities for improvement and develop initiatives.
- Performs Quality reporting updates monthly, quarterly, and annually, including but not limited to:
- Quality Update Report (QUR): prepare and submit monthly report to regional and senior management to communicate updates of Quality Assessment and Performance Improvement areas.
- QAPI IDG Committee Meeting (quarterly): prepare documents, co-facilitate meeting, capture minutes, submit documents, follow up on actions items from meeting.
- Annual Reports: complete QAPI Program Annual Evaluation, prepare Annual Program Operational Review for program management completion, and any state-specific requirements.
Facilitates Performance Improvement Projects including the coordination of performance improvement teams
Maintains Documentation of Performance Improvement Initiatives (both hard copy and electronic). Maintains any and all versions of the PI Plan Manual.
Identify program needs based on data analysis of the quality monitoring activities and recommend training to address these needs.
Report to senior management on compliance with required trainings including orientation and legally- mandated in-services.
Act as the program liaison to Central Support:
- Submission of quarterly QAPI IDG and annual report documents including policy recommendations via the Governing Body Report.
- Regarding quality initiatives: provides field perspective and participates in the development of company-wide materials.
Collaborates with the PCA for external audits and records requests. Participate in pilot projects related to QAPI initiatives as requested.
For programs or regions with a Performance Improvement Specialist (PIS) Assistant:
- Oversight of the Performance Improvement Specialist (PIS) Assistant, including delegation of approved tasks and mentorship for delegated tasks as needed.
- Other duties as assigned.
JOB REQUIREMENTS
- Ability to work independently and prioritize activities to meet deadlines.
- Detail oriented with ability to analyze quality data and identify trends.
- Strong oral and written communication, presentation, and facilitation skills.
- Strong computer and technology skills (including MS Excel, MS Word, MS PowerPoint, MS Teams, and MS Outlook).
- Strong organizational skills with the ability to multi-task.
- Ability to motivate and lead change management and performance improvement.
- Ability to travel as required.
JOB QUALIFICATIONS
- Licensed (as required) health care professional (preferred) or non-clinician with quality background.
- Certified Professional in Health Care Quality (preferred).
- Knowledge of Medicare/Medicaid regulations, state licensure laws, and the requirements of any other applicable regulatory/accrediting body.
- Experience with data collection, measurement tools, and data analysis.
- Experience in a quality assurance/improvement role with an understanding of performance improvement concepts preferred.
REASONABLE ACCOMMODATIONS
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job.
DIRECTION
Per the VITAS QAPI Plan, the General Manager/designee (with the cooperation of the Performance Improvement Specialist/designee) is responsible for coordinating and facilitating all QAPI activities. Therefore, the PIS Reports to the General Manager, or designee in the absence of the GM.
