Performance Improvement Specialist
Posted on: January 17, 2023
Job DescriptionThe primary function of the Performance
Improvement Specialist is to support and facilitate quality
assessment and performance improvement (QAPI) activities for the
local hospice branch (also referred to as hospice program). The
QAPI Program is an on-going, data driven, organization-wide program
involving data collection, analysis, and collaborative development
of performance improvement initiatives. Performs quality monitoring
activities (tracking, trending, and analysis) including, but not
- Hospice Quality Reporting Program (HQRP): data collection and
analysis of data associated with HQRP components, including but not
limited to: Consumer Assessment of Healthcare Providers and Systems
survey (CAHPS), claims-based measures, Hospice Item Set and any
- Care Compare: data collection, tracking, and benchmarking HQRP
scores against competitors.
- CAHPS analysis process (optional process): data collection,
analysis, and reporting.
- CAHPS survey: Identify negative comments/responses and initiate
service comments as appropriate.
- QAPI dashboard: drill down, analyze and report data.
- Service Comments: includes monitoring timely resolution,
reassignment of pending service comments, communication of trends
to program management, and ensure service comment log is
- Infection Control Reporting: data maintenance and
- Incident Reporting: data maintenance and analysis, submission
of documents for incidents identified as serious adverse events,
completion of 3500A for home medical equipment-related
- Root Cause Analysis (RCA): co-facilitate RCA meeting with
program management, ensure required documents are completed,
document meeting on appropriate templates, submission of documents
to required email distribution group, monitor effectiveness of
corrective action plan and report outcomes to program
- Revenue Analysis and Tracking: analyze and trend Unaccrued
Revenue using report provided by Revenue Cycle Management and
report findings to program management.
- Hospice Aide (HA) In-service hours: obtain training completion
report and report compliance with regulation requirement to program
- Annual Update HIPAA/OSHA: Obtain training completion report for
annual updates and report compliance to senior management.
- Physician satisfaction surveys (as required by the program):
data collection, analysis, and reporting.
- Revocation and discharge monitoring (as required by the
program): data collection, analysis, and reporting.
- Collect and analyze quality indicator data/key performance
indicators and collaborate with the senior management team to
identify priorities for improvement and develop initiatives.
- Performs Quality reporting updates monthly, quarterly, and
annually, including but not limited to:
- Quality Update Report (QUR): prepare and submit monthly report
to regional and senior management to communicate updates of Quality
Assessment and Performance Improvement areas.
- QAPI IDG Committee Meeting (quarterly): prepare documents,
co-facilitate meeting, capture minutes, submit documents, follow up
on actions items from meeting.
- Annual Reports: complete QAPI Program Annual Evaluation,
prepare Annual Program Operational Review for program management
completion, and any state-specific requirements. Facilitates
Performance Improvement Projects including the coordination of
performance improvement teams Maintains Documentation of
Performance Improvement Initiatives (both hard copy and
electronic). Maintains any and all versions of the PI Plan Manual.
Identify program needs based on data analysis of the quality
monitoring activities and recommend training to address these
needs. Report to senior management on compliance with required
trainings including orientation and legally- mandated in-services.
Act as the program liaison to Central Support:
- Submission of quarterly QAPI IDG and annual report documents
including policy recommendations via the Governing Body
- Regarding quality initiatives: provides field perspective and
participates in the development of company-wide materials.
Collaborates with the PCA for external audits and records requests.
Participate in pilot projects related to QAPI initiatives as
requested. For programs or regions with a Performance Improvement
Specialist (PIS) Assistant:
- Oversight of the Performance Improvement Specialist (PIS)
Assistant, including delegation of approved tasks and mentorship
for delegated tasks as needed.
- Other duties as assigned. JOB REQUIREMENTS
- Ability to work independently and prioritize activities to meet
- Detail oriented with ability to analyze quality data and
- Strong oral and written communication, presentation, and
- Strong computer and technology skills (including MS Excel, MS
Word, MS PowerPoint, MS Teams, and MS Outlook).
- Strong organizational skills with the ability to
- Ability to motivate and lead change management and performance
- Ability to travel as required. JOB QUALIFICATIONS
- Licensed (as required) health care professional (preferred) or
non-clinician with quality background.
- Certified Professional in Health Care Quality (preferred).
- Knowledge of Medicare/Medicaid regulations, state licensure
laws, and the requirements of any other applicable
- Experience with data collection, measurement tools, and data
- Experience in a quality assurance/improvement role with an
understanding of performance improvement concepts preferred.
REASONABLE ACCOMMODATIONS Reasonable accommodations may be made to
enable individuals with disabilities to perform the essential
functions of the job. DIRECTION Per the VITAS QAPI Plan, the
General Manager/designee (with the cooperation of the Performance
Improvement Specialist/designee) is responsible for coordinating
and facilitating all QAPI activities. Therefore, the PIS Reports to
the General Manager, or designee in the absence of the GM.
Keywords: VITAS, Pembroke Pines , Performance Improvement Specialist, Other , Clewiston, Florida
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