Quality Improvement Specialist

JOB SUMMARY

The Quality Improvement Specialist (QIS) works directly under the supervision of the Director of Compliance, who has overall responsibility to ensure congruence between St. Mary’s Home’s policies, procedures, and practices and St. Mary’s mission, vision, and values; and compliance with all federal, state, and local regulations. The QIS provides back-up for Risk Management duties. 

PRIMARY RESPONSIBILITIES

Regulatory Compliance:

• Develop new and revise current operating policies and procedures as necessary to ensure compliance with current federal, state, and local regulations.
• Coordinate the full life cycle of policies, including providing information to policy owners as they draft and revise policies, supporting review by the Policy Committee by providing the agenda for the monthly policy review meeting, facilitating approvals and signatures, publishing policies, and archiving older versions. 
• Maintain a separate Word directory of all policies, guidelines, and forms being used in the facility.  
• Assist in the development, implementation, and monitoring of new processes, policies, procedures, guidelines, and forms.
• Act as a resource for answering questions related to ICF/IID regulatory standards, as well as state and local regulations.
• Assist with completion of paperwork during regulatory reviews (Life Safety Code inspections and ICF surveys).
• Ensure retention policies meet regulatory requirements and adherence of the organization to retention requirements. 

Quality Auditing:

Perform utilization reviews of direct services delivered to individuals served at St. Mary’s to verify consistency between current practices and St. Mary operating policies and procedures.

• Complete quality improvement activities, collecting and analyzing data to implement positive change based on results.
• Design charts, graphs, and/or dashboards to communicate findings.
• Collaborate closely with the Director of Compliance in all quality assurance and compliance matters, reporting any concerns or gaps as soon as possible.
• Assist in the development of compliance and quality assurance training materials and perform quality assurance and compliance training as needed.
• Take the lead on obtaining systematic satisfaction data from people supported, employees, families, and other professional stakeholders.
• Perform reviews of all related services provided by St. Mary’s to ensure compliance with existing policies and procedures (i.e., Business Agreements, licenses and liability insurance annual requirements from contractual employees/companies). 
• Provide regular reports on all review activities to immediate supervisor and other department managers as scheduled and offering consultation as needed.
• Provide ongoing advice and resources to the Director of Compliance and Senior Leadership team for compliance and quality assurance issues and processes while monitoring improvement and implementations.
• Research, analyze, and contribute to the development and implementation of new quality measures and methods. 
• Review service documentation to ensure it is being done timely and correctly.
• Assist with safety reviews of the living environment. 

Other Related Duties:

• Serve as back up for Risk Manager.  
• Complete investigations of events as needed.  
• Assist with inventory and fixed assets tracking.
• Performs other duties as assigned by the immediate supervisor.

CONDUCT & VALUES

• Demonstrate kindness, patience, and compassion in all interactions.
• Collaborate effectively with all team members and leaders.
• Approach challenges with creativity, professionalism, and a positive, solution-oriented mindset.
• Model St. Mary’s values of kindness, fun, compassion, collaboration, engagement, and person-centered care in all aspects of work.
• Consistently uphold the standards of the organization by following all policies and procedures.
• Work in a prompt and efficient manner. 
• Attend all mandatory training sessions and complete mandatory training prior to the deadline.  

REQUIRED EDUCATION & EXPERIENCE

• Bachelor’s Degree in a Human Services field required; Master’s Degree preferred.
• A minimum of 3 years’ previous experience in developmental and intellectual disabilities services in an ICF/IID.  
• Experience in data analysis preferred.  
• At least one year of experience on an interdisciplinary team addressing the residential, programmatic, or educational needs of individuals with an intellectual disability or other related conditions preferred.  
• Must have experience interpreting federal and state regulations pertaining to the development and operation of Intermediate Care Facilities for Persons with Intellectual Disabilities (ICF/IID).

Knowledge, Skills, and Abilities

• Expertise in ICF/IID standards and regulations. 
• Knowledge of:
• and ability to interpret and apply relevant state and federal laws, statutes, and regulations.
• principles and practices of inspection, evaluation, compliance, and quality improvement 
• state policies and local ordinances
• principles and practices of health inspectors and fire inspections
• modern methods of care, treatment, and education of individuals served with an intellectual or developmental disability
• Must have excellent written and verbal communication skills. 
• Experience with electronic health records, Microsoft Office, and other databases. 
• Ability to perform inspections and individual reviews and evaluate active treatment service.
• Demonstrated organizational skills and the ability to multitask and meet project deadlines.
• Capable of working well with all levels of the organization.
• Must have some schedule flexibility to accommodate the agency’s needs as applicable. 
• Must complete all DBHDS and Human Rights (OHR) training necessary to serve as Risk Manager and complete investigations if needed. 
• Must complete 2-day Person-Centered Thinking training through The Learning Community for Person-Centered Practices
• Must possess a valid Driver’s License.
• Proficient in speaking, reading, and writing the English language required.

Physical and Other Requirements

• Must be able to sit, stand, walk, bend, and squat for variable periods of time.
• Must possess sufficient visual, auditory, and verbal abilities to perform essential job functions.
• Must wear company-issued ID badge at all times.
• Must be able to successfully obtain CPR certification and pass the Home’s behavioral and crisis management class.