Manager, QAPI and Education

Mary Washington Hospice

Mary Washington Home Health and Hospice
Fredericksburg, VA



day shift


Job Summary:
This position serves as the Quality Assessment/Performance Improvement and Education Manager for Mary Washington Home Health or Hospice and Palliative Services.  This position is responsible for the overall development and oversight of the quality assurance (QA) and performance improvement (PI) program, including coordination, development, reporting, improvement activities, and quality strategic planning.

As an EOE/AA employer, the organization will not discriminate in its employment practices due to an applicant's race, color, religion, sex, sexual orientation, gender identity, national origin, and veteran or disability status.
Essential Functions & Responsibilities:
Quality Assurance and Performance Improvement 

Develops, manages, and implements all components of the QAPI program for assigned service lines and serve as lead representative and content expert for assigned Mary Washington Healthcare committees and workgroups as needed. Schedules and facilitates quarterly PI meetings and annual Professional Advisory Committee meetings. 
Provides organizational leadership and acts as a resource for the evaluation, creation, and selection of performance improvement indicators to facilitate and promote efficient and effective clinical and operational programs.  
Actively identifies and evaluates clinical and operational improvement opportunities based on data analysis, healthcare, and homecare trends utilizing evidence-based performance improvement methodologies and tools.   Coordinates and oversees submission of all PI data and reports as needed. 

Defines and implements process improvements on key initiatives resulting in improvements in service delivery, organizational effectiveness and increased safety for staff and patients. Continuously assesses and improves department's performance based on customer needs; directs and participates in improving performance and services which benefit staff and other customers.

Education and Training

Responsible for the development and implementation of the annual education plan based on educational needs assessment of Associates. Ensures ongoing educational programs and training opportunities are available for all staff, including orientation of new Associates and relevant in-service education sessions. Ensures performance, coaching, and evaluation occurs and develops Associates using performance management.

Serve as primary Credentialed Trainer for Epic. Oversees and coordinates training for all new Associates. Maintains and updates training materials as needed. Provides tip sheets and follow up education to staff as identified.
Works directly with clinical and operations leadership teams to ensure that Electronic Medical Records is built appropriately to meet regulatory and compliance guidelines. Works with the EMR build team directly to provide guidance regarding clinical build needs and provides specific regulations when requested.

Regulatory Compliance 

Provides managerial oversight and monitors regulatory compliance in all coding, data abstraction and analysis functions/staff. Collaborates with department leadership in the development and maintenance of all policies/procedures as mandated by state and federal regulations or other policies related to the organization. Collaborates with department leadership to create and execute steps and activities that will demonstrate compliance with regulatory agency requirements.
Proactively identifies and works with department Directors and Managers to address risk areas and all matters related to compliance, including coordinating internal investigations, root cause analyses, and corrective action plans as needed.  
Serves as lead and point of contact and liaison for all regulatory surveys and inquiries.  Assist department leadership with preparation and submission of all required information and documentation for regulatory and other inquiries and requests as needed. 


Consistently represents department to all internal and external customers with integrity and professionalism and carries out duties and responsibilities of position in a manner that exemplifies excellent customer service. 
Proactively establishes, promotes, and maintains effective relationships with internal and external stakeholders to include clinical staff, Physicians, department and organization leadership, and outside regulatory bodies and agencies.  
Develop and deliver written and visual communications and presentations to internal and external stakeholders as necessary.  This may include written Board of Director reports, regulatory and governmental follow ups and correspondence, as well as educational and other updates to staff and other organizational entities.  
Integrates department's services with MWHC primary functions by supporting organizational mission, priorities and goals, and by delivering optimal quality health care services.
Participates in Administrator on call rotation and provide operational managerial oversight and coverage for peer managers and Director as needed.  
Responsible for hiring, developing, coaching, discipline, and performance evaluations.
Completes other tasks as assigned.

RN licensed to practice in Virginia is required.
BSN required, MSN preferred.
Two (2) years coordinator or leadership experience preferred.

Hospice and Palliative Services Additional Duties and Responsibilities (December 2018)
Manages and oversese the medical records Department for Mary Washington Hospice.  Actively works with other Department managers and Director to ensure and maintain compliant patient records.
Serves as active and engaged member of the Palliative Services Council and oversee all data analytics for the Palliative Care Program. Organize and oversee the annual submission of necessary data for benchmarking (i.e., CAPC National Registry). 
Assists Hospice and Palliative Clinical Manager with departmental and organizational education initiatives and programs  (i.e. ELNEC, Advance Care Planning, etc.) 
Maintains competence and professional expertise by completing continuing education as required by licensure and/or certification. Proactively identifies education opportunities for Department and works with Director to identify and attend webinars and conferences as able.