RN- QAPI Coordinator

Job Description

The QAPI Coordinator under the direction of Hospice management is responsible for implementing an on-going, comprehensive, integrated, quality performance improvement program. This program is patient-centered, data driven and outcome-based which meets the CMS requirements. The coordinator acts as a clinical resource and consultant to the Hospice Program and QAPI Committee.   The QAPI/Education Coordinator acts as a change agent and teacher in the areas of clinical practice, clinical documentation and compliance with accreditation and regulatory requirements. Creates and provides Quality Assessment/Performance Improvement education through educational events, one-on-one consultation, QAPI bulletin board displays and other methodologies.

 

Demonstrate respect, dignity, kindness and empathy in each encounter with all patients, families, visitors and other employees regardless of cultural background.

 

SECTION II – KNOWLEDGE, SKILLS & EXPERIENCE – Include Desirable Section

 

List the minimum knowledge and skills required to begin working in this position and the additional knowledge and skills that are desirable, but not essential. 

 

MINIMUM

DESIRABLE

Education, Credentials, Licenses:

 

RN with licensure in the state(s) of practice. Obtain 30 CEUs biannually, including all state required courses. Current Kentucky driver’s license.

 

 

BSN or other bachelor’s level degree; Certification in Hospice and or quality assurance field.

Specialized Knowledge: 

 

-Knowledge of state and federal hospice care regulations -SEMC policies and procedures

-Organization skills

-Communication skills

- Human Relations skills

- Basic statistical and spreadsheet knowledge

 

 

 

Kind and Length of Experience: 

3 years of experience in acute care environment

3 years of experience in hospice care as a case manager or clinical team leader.

Experience coordinating a quality performance program. Experience in designing and leading education programs.

 

SECTION III – MAJOR ACTIVITIES AND END RESULTS

 

List, in brief statements, the major activities and end results for which this position is accountable.  Most positions will have between five and eight major activities/end results. Describe the position so that someone unfamiliar with your position will understand what is done, and why it is done. Weigh each major activity/end result based on its importance relative to the total job (i.e.: 10%, 20%, 45%).      

 

 

 

Job Duties

Insert “*” to classify Essential Function

% of Time (must total 100%)

1

Quality Assessment:

Coordinates the measuring and tracking of indicators of quality related to all aspects of the Hospice Program. Assess where the hospice program is performing well and where there is an opportunity for improvement of outcomes, quality and performance.  Assists with the development of quality measures, collects data, analyzes and develops action plans and reports to the QAPI Committee.

*

20%

2

Performance Improvement:

Assists with the selection of performance improvement indicators that are data driven to develop a performance improvement plan that is focused on improving Hospice program performance. Initiates and/or facilitates ongoing interdisciplinary Performance Improvement Project (PIP) teams.

*

20%

3

Regulatory Requirements:

Participates in collecting and collating all QAPI data in a manner that is easily displayed in metric form for presentation at monthly and quarterly meetings to the QAPI Committee and other regulatory bodies. Presents the QAPI program to State Surveyors, Joint Commission and other regulatory groups as requested. Stays current on CMS quality measures related to hospice care.

*

20%

4

Documentation:

Assures that the Hospice’s performance improvement activities include focus on high risk, high volume, and problem-prone areas. Considers incidence, prevalence, and severity of problems in those areas identified and includes palliative outcomes, patient safety and overall quality of care. Utilizes organizations quality tools for the documentation of quality assessment and performance improvement activities.

*

15%

5

Communication:

Responsible for maintaining a positive relationship with all members of the interdisciplinary group and community organizations concerned with hospice.  Participates in local professional organizations and activities to stay current with new developments or technologies and to promote St. Elizabeth Hospice in the marketplace.  Demonstrate ability to write clear and concise reports.

*

10%

6

Education:

Responsible for initial and on-going education of all Hospice staff related to the quality assessment and performance improvement program. Attends all required performance improvement committee meetings and prepares monthly, quarterly and annual reports on the overall success and opportunities of the QAPI Program.  Creates and provides Quality Assessment/Performance Improvement education through educational events, one-on-one consultation, QAPI bulletin board displays and other methodologies.

*

5%

7

Personal Growth and development :                                                                                                 

Is available to serve on committees to represent Hospice Program.

Maintains certification as a Hospice nurse.

Attends in-services, seminars or continuing education offerings related to Hospice and Palliative Care to increase knowledge.     

*

5%

8

 

 

 

9

 

 

 

10

Performs other duties as assigned.

 

5%

 

TOTAL:

100

NOTE:  Remove blank rows and use mouse to right-click on total amount above.  Click “update field” from list for auto-sum~

 

The associate shall follow the applicable safety steps required to perform their duties to ensure safety for themselves and their patients, and be in compliance with Medical Center, State, and Federal safety standards.  Examples of such steps may include:  performing proper safety procedures and precautions; reporting safety concerns and incidents; using correct lifting techniques and disposing of sharps and infectious waste properly.

 

For Clinical and related positions - The associate must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served on their assigned unit.  The associate must demonstrate knowledge of the principles of growth and development over the life span focused on the assessment, treatment and care of the newborn, infant, pediatric, adolescent, adult, and geriatric patients.             

                 

Required:  Employee must successfully complete an orientation process that identifies skills needed to practice in their position and in their job assignment. Skill requirements must be met and maintained to ensure employee competency. This is achieved through an annual review of those particular skills and a work improvement plan for any non-compliant area.

 

SECTION IV – PROBLEM SOLVING

 

Briefly describe two or three typical problems this position must resolve to achieve the end results listed in Section III.   

           

                The QAPI Coordinator must assure that the program encompasses all aspects of the Hospice operations. This includes development of indicators that reflect both clinical and non-clinical services. An example would be a routine audit of hospice bills that reflect service in the home, inpatient unit, skilled nursing facility and residential care to determine that all charges are properly represented.                                                               

 

SECTION V – SCOPE OF POSITION

 

1

Who (by title) does this position report to?    

Director

  • Indicate type of supervision provided (Direct or Indirect?)

Indirect

2

Who (by title) reports directly to this position?

N/A

  • Indicate type of supervision provided (Direct or Indirect?)

N/A

3

Total number of FTE’s reporting to this position:

N/A

4

Annual operating budget (if applicable):

N/A

5

Other dollar measures of accountability?

N/A

 

SECTION VI – WORKING CONDITIONS

 

Describe unusual working conditions such as physical effort, exposure to environmental conditions and exposure to hazards.

                Position requires walking daily and possible exposure to blood and body fluids.  It also will require driving in all kinds of weather.  All employees shall be able to perform their duties in a safe manner for themselves, their patients and in compliance with medical center, state and federal safety standards.

 

SECTION VII – ADVANCEMENT TO NEXT POSITION

 

Identify the most likely future position(s) of advancement.  This position(s) may be a higher level or equivalent level job within or outside the department.  Advancement criteria, such as required technical knowledge (skills, education, experience), managerial capabilities, and problem solving skills should also be noted. 

 

Next Likely Position(s):

Assistant Nurse Manager

Advancement Criteria:

Meets or exceeds performance standards

Vacant position

Meet or exceed minimum qualifications for next level