What are the responsibilities and job description for the VP, Quality and Compliance position at Alive Hospice?

Job Description

SUMMARY

The Vice President, Quality & Compliance provides direction and oversight of performance improvement through data and quality and compliance measurements to provide direction and oversight of the QAPI with leading process improvement efforts to ensure compliance with agency, local, state and national quality initiatives.

The Vice President, Quality & Compliance is also responsible Identifying and assessing areas of compliance risk for the organization; communicating the importance of the QAPI program to executive management and the Board of Trustees; preparing and distributing the written Code of Conduct setting forth the ethical principles and policies, which are the basis of the Compliance Program; developing and implementing education programs addressing compliance and the Code of Conduct; implementing a retaliation-free internal reporting process, including an anonymous telephone reporting system; and collaborating with executive management to effectively incorporate the Compliance Program within system operations and programs and to carry out the responsibilities of the position.

For purposes of clarification, Compliance is defined as all health care regulatory compliance including OIG, CMS, TJC, and HIPAA and other regulations that directly or indirectly impact the operations of Alive Hospice.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Quality

Collaborate with the VP of Information Technology and Security for optimization of Agency information systems to support and improve processes
Facilitation of Root Cause Analysis (RCA), Failure Mode Effects Analysis (FMEA), and Performance Improvement efforts
Data gathering to identify opportunities for performance improvement
Collaboration with all stake holders to ensure reporting needs are identified and met
Analytic support for departments across the organization
CMS quality reporting
Incident reporting and service recoveries
Collaborate with Deyta for collection and reporting of family satisfaction surveys
Contract management
Electronic Medical Record (EMR) enhancement support
Collaborate with VP of Information Technology and Security to design and / or refine data tools and systems to streamline agency processes
Compliance
Monitoring the Compliance Program to help the organization prevent and / or detect violation of law, regulations, policies, or the Code of Conduct.
Regularly reviewing the Compliance Program and recommending appropriate revisions and modifications, including advising Executive Management and the Board of Trustees of potential compliance risk and
Coordinating resources to ensure the ongoing effectiveness of the Compliance Program.
Implementing and operating retaliation-free reporting channels, including an anonymous telephone reporting system available to all employees, volunteers, and affiliated providers telephone reporting system available to all employees, volunteers, and affiliated provider

Developing education programs for all employees, agents, affiliated providers, or others working with the organizatio

Ensuring that the internal controls are capable of preventing and detecting significant instances or patterns of illegal, unethical, or improper conduct by employees, agents, affiliated providers, or others working with the organizati

Ensuring that the system has effective mechanisms to reasonably determine that persons either promoted to or hired in management and certain other sensitive and / or responsible positions (to be designated) do not have a propensity to violate federal or state laws and regulations or engage in improper or unethical conduct in their designated areas of responsibility.

Providing input and / or direction to Human Resources policies and procedures and the performance appraisal and incentive programs to ensure that improper conduct is discouraged and that support of and conformity with the Compliance Program is part of any performance evaluation process for all employ

Coordinating as appropriate with outside legal counsel, conducting or authorizing and overseeing investigations of matters that merit investigation under the Compliance Program.

Overseeing follow-up and, as applicable, resolution to investigations and other issues

generated by the Compliance Program, including development of corrective action plans, as needed.

Tracking all issues referred to the Compliance Offi

Developing productive working relationships with all levels of management.

Presenting periodic and annual reports on the Compliance Program to the Board of Director

Developing and implementing, upon an approval by executive management and the Board of

Directors, an annual review of an update to the Compliance Pl

Reporting on a regular basis to the Board appointed Quality and Compliance Committee on matters involving the Compliance Program. Additionally,

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