Director Quality Improvement

TX-HHSC-DSHS-DFPS•Harlingen, TX

1d•$6,800 - $10,786•Onsite

About The Position

Join the Texas Health and Human Services Commission (HHSC) and be part of a team committed to creating a positive impact in the lives of fellow Texans. At HHSC, your contributions matter, and we support you at each stage of your life and work journey. Our comprehensive benefits package includes 100% paid employee health insurance for full-time eligible employees, a defined benefit pension plan, generous time off benefits, numerous opportunities for career advancement and more. Explore more details on the Benefits of Working at HHS webpage. Performs advanced (senior-level) managerial work administering the daily operations and activities of the department of quality improvement at the State Supported Living Center (SSLC). Establishes, implement and oversees goals and priorities for the Quality Improvement department. Oversees a proactive, organization-wide quality systems approach by surveilling performance data and identifying where in the system the Center needs to focus improvement efforts. Oversees the SSLC’s efforts to optimize the effectiveness of processes, improving outcomes for individuals, improving stakeholder satisfaction, and overhauling systems. Proactively identifies issues and provides solutions. Provides and oversees provision of technical assistance, support, and training to department heads and other staff assigned to program compliance and quality improvement work in the use of QI tools, data analysis, and auditing. Oversees the preparation and to annual survey, annual state-wide review by the state-office team, and regulatory audits. Acts as the liaison before, during and after monitoring visits. Directs and oversees the functions of the quality assurance department including providing support to departments in data collection, monitoring, analysis, and reporting. Provides leadership and plans, assigns, supervises the activities of the quality improvement department and client records department staff. Directly supervises the systems improvement specialist, program auditor(s), data analyst(s), records coordinator, Quality Assurance Nurse(s) and administrative/clerical staff. Manages the center’s data surveillance system. Oversees the work of data analysts to ensure statistical analysis of data and database design is conducted and maintained. Oversees the Center’s QA/QI Council. Functions as a member of the Executive Team and the QA/QI Council and typically participates in the Executive Duty Officer/Administrative Duty Officer process and Mortality Review Committee. Interfaces with the state office leadership via regular conference calls and face-to-face meetings. Prepares assigned reports. Reviews, evaluates, advises and trains on the impact of proposed and actual changes federal and state laws. Oversees the analysis, training, and implementation of HSCS and SSLC policies, and monitors compliance with policies and procedures as directed such as the incident management policy, the restraint policy and the quality improvement policy. Works under limited supervision, with considerable latitude for the use of initiative and independent judgment. (Serves in an on-call rotation, as assigned.) Essential Job Functions (EJFs): Attends work on a regular basis and may be required to work a specific shift schedule or, at times, even a rotating schedule, extended shift and/or overtime in accordance with agency leave policy and performs other duties as assigned. (Serves in an on-call rotation, as assigned.) Oversees the SSLC’s efforts to optimize the effectiveness of processes, improving outcomes for individuals, improving stakeholder satisfaction, and overhauling systems. Assists department heads in creating and overseeing the work on quality improvement plan teams using a structured process for creating the team, establishing roles, analyzing the issue, related data, and its contributing factors, drafting a goal statement, developing change ideas, implementing the PDSA cycles and monitoring and optimizing the change to confirm it is long-lasting. Proactively identifies issues and provides solutions. Participates in face-to-face meetings with each department lead at least quarterly in order to promote and oversee a culture of quality which includes review of all data, defined action strategies that promote teamwork, transparent communication, a focus on processes, innovation and improvement and engages front line staff to provide insight into processes and past decisions. Provides and oversees provision of technical assistance, support, and training to department heads and other staff assigned to program compliance and quality improvement work in the use of QI tools, data analysis, and auditing. This technical assistance includes the PDSA cycle, completing a contributory factor analysis, formulating a problem or aim statement when creating a corrective action plan. Leads others in the successful implementation of the 5 Whys technique to make informed decisions about root causes of problems. Provides assistance and guidance in facilitating brainstorming and prioritization sessions, identifying improvement metrics and developing strategies to collect the data for discipline-specific improvement projects and helps departments to organize, analyze, and visually display the data. Directs and oversees the functions of the quality assurance/improvement department. Provides leadership and plans, assigns, supervises the activities of the quality improvement department and client records department staff. Directly supervises the systems improvement specialist, program auditor(s), data analyst(s), records coordinator, Quality Assurance Nurse(s) and administrative/clerical staff. Supervises other types of staff as needed depending upon SSLC structure. Makes monitoring assignments to QI staff. Hires, trains, and promotes personal and professional growth of the employees within the department so that a competent workforce is maintained. Ensures that all departmental staff are compliant in training with agency and facility standards. Manages the professional development of QI staff including enhancing their skills in the use of monitoring tools, applied data analysis, root cause analysis, Plan-Do-Study-Act (PDSA) cycle, and use of systems to track and display data. Takes action to address training and staff development needs. Conducts performance evaluations of assigned staff to give employees timely feedback on their performance and oversees staff development plans and activities. Takes action to improve employee retention and reduce turnover. Oversees and manages the center’s data surveillance system, reviewing and coordinating the systems and processes to retrieve, track, validate and trend data. Provides support to departments in data collection, monitoring, analysis, and reporting. Ensures the collection of information in a timely and efficient manner and ensures the use of that information to identify performance issues and make decisions. Proactively identifies potential and actual problems by reporting them to the appropriate supervisor/manager for corrective action. Provides feedback to department heads for process improvement. Establishes, implement and oversees the goals and priorities for the Quality Improvement department including promoting a culture of quality by fostering a blame-free, inquisitive environment that fosters collaboration, creativity, and psychological safety. Ensures the goals and priorities include using a proactive, organization-wide quality systems approach by surveilling performance data and identifying where in the system the Center needs to focus improvement efforts. Implements a model for quality improvement that includes action strategies for department heads such as including the input of the frontline staff, residents and their families, guiding and empowering staff to solve problems, avoiding duplication and waste, using the Plan-Do-Study-Act (PDSA) model for change, using data to inform and track change, developing communication strategies that promote and communicate change, and creating a system where all staff members have the necessary equipment, skills, and knowledge to do their jobs. Serves as a subject matter expert to the data analysts, quality assurance specialists/program auditors and others in analyzing and visualizing data. Assists them in organizing and summarizing the data, interpreting the data displaying the data effectively to help others understand it such as by using charts and graphs, and communicating to others what the data means. Ensures data displayed in the SSLC Key Indicator Platform (SKIP) is complete and correct. Collaborates with, and manages data analyst collaboration with, the state office data analysts to validate and correct datasets in the electronic records system and improve data integrity. Oversees the preparation for, and response to, annual survey and regulatory audits. Acts as the liaison between HHSC-Regulatory and the facility before, during and after monitoring visits. During visits from HHSC-Regulatory, meets with surveyors at the entrance and exit meetings. Ensures surveyors receive all documentation requested, providing contact information for staff, residents and families as needed. Answers surveyor questions regarding policies/procedures. Notifies all required parties of the entrance of HHSC-Regulatory at the SSLC in accordance with established protocols. Responds to Regulatory concerns and takes immediate action to resolve the issue(s). Oversees the development and submission of a plan of correction (POC) for all deficiencies cited by HHSC-Regulatory. Ensures POCs include measurable outcomes and appropriately address the identified issue(s), that the outcomes are monitored. Ensures that all due dates noted in the POC are met, and that evidence supporting the plan is collected and organized in accordance with the SSLC protocol. Presents the evidence to the surveyors upon their return visit. Attends the HHSC-Regulatory quarterly provider meetings and regional trainings. Reviews and evaluates the impact of proposed federal and state laws, such as new or changing rules to the Texas Administrative Code or Centers for Medicare and Medicaid Services (CMS) ICF/IID requirements, on program objectives and program operations. Advises the SSLC’s leadership on program changes that are needed. Oversees or provides training to all staff on the required changes. Oversees the Center’s QA/QI Council which sets priorities, establishes goals and monitors the progress of performance improvement activities. Creates the agenda and schedule of presentations, advises on presentation content, reviews all reports, and, if requested by the Director, facilitates the meeting. Maintains a system to accurately reflect all monitoring to be reviewed by QA/QI Council. Works with the SSLC Director to ensure all necessary data is reviewed by the QA/QI Council on a recurring schedule. Participates on other work groups as needed to promote collaboration and operational effectiveness as assigned. Attends the daily Incident Management meeting to ensure that injuries and incidents are addressed appropriately. Functions as a member of the Executive Team and the QA/QI Council and typically participates in the Executive Duty Officer/Administrative Duty Officer process and Mortality Review Committee. Interfaces with the state office leadership via regular conference calls and face-to-face meetings. (10%) Oversees the analysis, training, and implementation of HSCS and SSLC policies, and monitors compliance with policies and procedures as directed such as the incident management policy, the restraint policy and the quality improvement policy. Provides technical guidance for staff within the department or facilitates getting that guidance from other subject matter experts when needed. Develops localized policies and procedures as needed and ensures those documents are posted on the required site and are updated as needed. Develops in-service/training modules as needed to address issues. Ensures all staff are trained on policy changes as required. Ensures in-services/trainings on policies and procedures are conducted in conjunction with POCs and documentation is accurately maintained. Prepares required reports such as the annual quality plan and the monthly QAQI report. Oversees SSLC preparation for the annual review by the State-Office State Review Team (SRT). Ensures documents are pulled and shared with the appropriate areas for monitoring. Uses the self-assessment tool for Section E to evaluate the QI systems at the center. Develops interrater reliability with state-office QI staff members. Identifies areas of needed change and develops new departmental procedures to improve programs and services. Other duties as assigned include but are not limited to actively participating and/or serving in a supporting role to meet the agency’s obligations for disaster response and/or recovery or Continuity of Operations (COOP) activation. Such participation may require an alternate shift pattern assignment and/or location.

Requirements

Bachelor’s degree from an accredited college or university; and three (3) years of work experience in service delivery systems for persons with intellectual disabilities or in quality assurance (or a combination of the 2); or High school diploma/GED and seven (7) years of work experience in service delivery systems for persons with intellectual disabilities, including at least two (2) years in a role with duties relating to quality assurance.
Experience with the standards, applicable rules, and laws related to ICF/IIDs or other acute or long-term care settings.
Knowledge of ICF/IID Standards, interpretive guidelines and survey process.
Knowledge of Texas Administrative Code, HHSC policies and procedures related to State Supported Living Centers, and applicable federal rules and regulations.
Knowledge of and experience in ensuring the provision of quality services, treatment, training and supports for individuals with intellectual disabilities.
Knowledge of how to use tools such as pivot tables, scatter charts, wishbone diagrams, histograms and pareto charts to effectively communicate data.
Knowledge of basic quality improvement concepts and terminology.
Skill in managing a robust data surveillance system.
Skill in defining problems, collecting data, establishing facts, conducting root cause/contributory factor analysis.
Skill in using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems.
Skill in using computers and agency/facility software including, but not limited to, Microsoft Word, Excel, PowerPoint, Outlook, and SharePoint.
Skill in helping others to define complex problems.
Skill in motivating all levels of staff.
Skill in facilitating change.
Skill in writing quality improvement plans.
Ability to develop written policies/guidelines to ensure facility compliance with applicable standards.
Ability to manage business functions and activities of the assigned department.
Ability to gather, assemble, and correlate data for trend analysis.
Ability to effectively facilitate work groups and meetings.
Ability to organize and present information effectively, both in spoken and written word, to a wide variety of audiences.
Ability to analyze and solve complex problems and to make effective decisions affecting the overall operation of the facility.
Ability to plan, assign, and supervise work of others.
Ability to manage time with latitude for independent judgement.
Ability to maintain flexibility in work hours, which may require overtime or extended hours.
Must pass a fingerprint criminal background check, pre-employment drug screen, and registry checks including the Client Abuse/Neglect Reporting System (CANRS), Nurse Aide, Medication Aide and Employee Misconduct and HHS List of Excluded Individuals/Entities (LEIE).
Males between the ages of 18 – 25 must be registered with the Selective Service.
All State Supported Living Center Employees are subject to Random Drug Testing.
Must be willing to work weekends and holidays.
All applicants must be at least 18 years of age to be considered for employment at a state-operated facility.

Nice To Haves

Experience with ensuring quality services for persons with intellectual and developmental disabilities is preferred.
Experience leading and/or supervising employees is preferred.

Responsibilities

Administering the daily operations and activities of the department of quality improvement.
Establishing, implementing, and overseeing goals and priorities for the Quality Improvement department.
Overseeing a proactive, organization-wide quality systems approach by surveilling performance data and identifying areas for improvement.
Optimizing the effectiveness of processes, improving outcomes for individuals, improving stakeholder satisfaction, and overhauling systems.
Proactively identifying issues and providing solutions.
Providing and overseeing technical assistance, support, and training to department heads and staff on QI tools, data analysis, and auditing.
Overseeing preparation for annual surveys, state-wide reviews, and regulatory audits.
Acting as the liaison before, during, and after monitoring visits.
Directing and overseeing the functions of the quality assurance department.
Providing leadership, planning, assigning, and supervising the activities of the quality improvement and client records departments.
Managing the center’s data surveillance system.
Overseeing the work of data analysts to ensure statistical analysis and database design.
Overseeing the Center’s QA/QI Council.
Serving as a member of the Executive Team and the QA/QI Council.
Participating in the Executive Duty Officer/Administrative Duty Officer process and Mortality Review Committee.
Interfacing with state office leadership via regular conference calls and face-to-face meetings.
Preparing assigned reports.
Reviewing, evaluating, advising, and training on the impact of proposed federal and state laws.
Overseeing the analysis, training, and implementation of HSCS and SSLC policies, and monitoring compliance.
Assisting department heads in creating and overseeing quality improvement plan teams.
Participating in face-to-face meetings with department leads to promote a culture of quality.
Hiring, training, and promoting personal and professional growth of departmental employees.
Ensuring departmental staff are compliant in training with agency and facility standards.
Managing the professional development of QI staff.
Conducting performance evaluations of assigned staff.
Taking action to improve employee retention and reduce turnover.
Reviewing and coordinating systems and processes to retrieve, track, validate, and trend data.
Ensuring the collection of information in a timely and efficient manner and its use for identifying performance issues.
Fostering a blame-free, inquisitive environment that promotes collaboration, creativity, and psychological safety.
Implementing a model for quality improvement that includes action strategies for department heads.
Serving as a subject matter expert in analyzing and visualizing data.
Collaborating with state office data analysts to validate and correct datasets.
Overseeing the preparation for, and response to, annual survey and regulatory audits.
Developing and submitting a plan of correction (POC) for all deficiencies cited by HHSC-Regulatory.
Advising SSLC leadership on program changes needed due to new laws or regulations.
Creating agendas and schedules for the QA/QI Council, advising on content, and reviewing reports.
Attending the daily Incident Management meeting.
Developing localized policies and procedures as needed.
Developing in-service/training modules as needed.
Ensuring all staff are trained on policy changes as required.
Preparing required reports such as the annual quality plan and the monthly QAQI report.
Overseeing SSLC preparation for the annual review by the State-Office State Review Team (SRT).
Identifying areas of needed change and developing new departmental procedures.
Actively participating and/or serving in a supporting role to meet agency obligations for disaster response and/or recovery or Continuity of Operations (COOP) activation.