Quality Management/Training Coordinator Position Description

UMAR

Quality Management/Training Coordinator Position Description

Position Title: Quality Management/Training Coordinator

Assigned Work Area: Corporate Huntersville

Supervisor: Director of Human Resources

Department: Human Resources

FLSA Status: Exempt

Positions Supervised: NA

General Position Description:

Responsible for the ongoing assessment, development, implementation, and management of educational and training services/programs for UMAR. Ensures programs/services achieve positive outcomes, and seeks to develop and improve employee knowledge/skill through various learning methods. Education and training will meet the needs of multiple sources including but not limited to: participants, purchasers of service, regulatory/accrediting bodies, and staff. Focus is given to best practices and the development of competencies for professional employees of behavioral healthcare organizations. This individual must spend 50 percent of his or her time in Quality Management activities and 50 percent of his or her time in Training Coordinator activities.

Must have working knowledge of all NC statutes and rules related to behavioral health standards, IDD standards and criteria, and clinical service definitions. Must have a working knowledge of all policies and procedures for UMAR, including participant rights, clinical policies, employee ethics, accessibility, and safety program. This position is responsible for coordinating all QI/QA activities and all required staff training. The QM/Training Coordinator is responsible for: Development of a quality improvement/quality assurance plan. Developing and reporting participant outcomes and comparing the agency's performance to outcomes achieved by other, similar providers. Development and implementation of a protocol for continuous staff training designed to achieve all requirements of the services being delivered.

 

Essential Functions:

The following reflects management’s definition of essential functions; performance expectations and competencies for this job but does not restrict the tasks that may be assigned. Management may assign or reassign duties and responsibilities to this job at any time due to reasonable accommodation or other reasons.

To perform this job successfully, an individual must be able to satisfactorily perform each of the duties and responsibilities outlined in this position description. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Must have a current driver’s license, which is in good standing. Must exhibit the ability to establish rapport and maintain effective relationships with internal and external customers and families. Experience with, and cultural sensitivity to work and/or serve a diverse population. Reacts well under pressure; treats others with respect and consideration regardless of their status or position; accepts responsibility for own actions; follows through on commitments and identifies and resolves problems in a timely manner.

Quality Management Duties

¨  Design, implement, supervise and monitor quality assurance and quality improvement for the agency.

¨  Develop, implement, and at least quarterly evaluate the agency's annual quality improvement/quality assurance plan. Revise the plan as needed.

¨  Develop agency-wide quality assurance and quality improvement processes with continuous staff, participant, family, stakeholder, and management involvement including participant, staff and stakeholder satisfaction survey(s);

¨  Establish and review agency data and performance indicators and metrics.

¨  Develop and monitor actions to address individual and aggregate trends, including critical incidents, adverse events, complaints, grievances, and quality of care measures including participant access, referral, transition, engagement, retention, and individual and aggregate outcomes.

¨  Oversee and direct staff to comply with all consumer data and records documentation requirements, staff qualifications, evidence-based practices training, implementation, supervision, evaluation and fidelity monitoring, CARF accreditation standards, reaccreditation requirements and reporting, auditing, and regulatory review requirements of federal, state, MCO and local agencies.

¨  Will develop Quality Assurance/Quality Improvement plan annually, and report on participant’ outcomes using benchmarks from similar providers, MCO’s and State data.

¨  Will work directly with the Clinical Service Departments, and the HR Department on all oversight activities.

¨  Will lead the Human Rights committee ensuring participant input, compile data from incident/accident reports and Health & Safety inspections to develop a HRC report to present at every meeting.

¨  Will assist with HR Director with review of investigations/adverse events and critical incidents.

¨  Implement CARF standards, and attend CARF trainings specifically around clinical outcomes.

¨  Will assume responsibility for maintaining and updating all organizational plans in accordance with CARF standards including but not limited to the accessibility, cultural competency, health & safety, quality management, risk management, strategic, technology, and training plans.

¨  Will be primarily responsible for preparing for CARF surveys and submitting a Quality Improvement Plan to address any recommendations the agency receives during the CARF survey.

¨  Complete and submit quarterly incident reports to the MCO’s that require the report on a quarterly basis.

¨  Work with Leadership Team and QPs to develop and submit plans of correction in response to deficiencies that may be found during DHSR and MCO audits.

¨  Will complete the annual DHSR relicensing packets/forms for all sites and ensure that all external site inspections and criteria are met to renew licensure.

¨  Will maintain an updated and accurate file for all sites at the corporate office to include but not limited to current DHSR licenses, internal and external inspections, emergency drills, and incident/accident reports.

Training Duties

¨  Reflects the agency's vision, mission and guiding principles; Includes goals, objectives, methods, budget and expected outcomes for the agency.

¨  Indicates that evidence-based training methods will be utilized.

¨  Identifies instructional training system design and development principles.

¨  Indicates the use of technology to increase access to and the effectiveness of training.

¨  Identifies implementation strategies to support and sustain the use of clinical skills in supporting the continuum of care within the agency.

¨  Implements training required by DMH/DD/SAS, MCO and DMA Clinical Coverage Policies.

¨  Ensures there is sufficient access to training and education opportunities, especially in rural areas and for culturally diverse populations.

¨  The Training Coordinator shall perform and document the following activities: (1) Maintain and produce to DHSR, MCO’s and DMA or its designee upon request training records which demonstrate that staff has the competencies to deliver integrated behavioral health care, emphasizing evidence based practices and quality improvement approaches, and that clinical supervisors have competencies to mentor and supervise staff in these practices.

¨  Plan, organize and direct all training activities.

¨  Identify organizational, departmental and service training needs within the agency.

¨  Conduct orientation sessions and arrange on-the-job training for new employees.

¨  Develop and offer supervisory training for staff in supervisory positions.

¨  Evaluate training effectiveness at least quarterly.

¨  Will demonstrate the ability to assess and determine educational and training needs for UMAR, and may include other behavioral healthcare providers. Will develop proposals and plans for meeting identified needs of the agency.

¨  Will design and implement educational training curriculums that evidence best practices and achieve positive outcomes. This will include the evaluation of services and ongoing revisions to improve effectiveness. These curriculums and materials include, but are not limited to: Ethics, Client Rights, Blood Borne Pathogens, Defensive Driving, NCI, First Aid/CPR, HIPAA compliance, Best Practices, CARF required trainings and organizational policies and procedures.

¨  Will obtain and maintain certification as an NCI instructor, CPR/First Aid instructor, blood borne pathogens instructor and other credentialing as required to train in all areas listed above. Will conduct these trainings for new employee orientation and recertification on a monthly basis.

¨  Will demonstrate knowledge and skill in the use of technology to research, develop, and deliver educational materials. This will include: computer hardware/software, web based applications including survey tools, and digital projectors. Must stay current and keep staff informed and trained on changes that impact the service delivery in NC, i. e., DMA, NC Division of MH/DD/SA, APSM, Service Records Manual, Implementation Updates, NC State budget initiatives, etc.

¨  Will develop educational training that is participant driven, marketable, and comparable in cost to other training services in the IDD, behavioral healthcare field.

¨  Will consult with outside trainers if necessary and schedule/manage regional trainings to ensure that required and/or needed trainings are provided to staff.

¨  Will implement the protocol for continuous staff training, maintaining the training database to ensure trainings are up to date, and that services are not provided by any staff member that has not had or shown competency on the required trainings.

¨  Will implement and have oversight to the annual training plan.

¨  Will coordinate with Supervisors, Managers and HR Director to ensure that training needs are identified and addressed.

¨  Will evaluate training on a regular basis and will make changes as needed.

 

Responsibilities & Duties:

Training

§  Management of training database.

§  Communicate training status to supervisors and staff.

§  Schedule training, and send reminders.

§  Create training certificates based on attendance sheets.

§  Follow up with staff after training by sending a Training Evaluation.

§  Enter training evaluation data and produce reports.

§  Research and provide staff development and participant education training and topics.

§  Development of on line (electronic – power point presentations) for all organizational and other training as needed.

Assigned Responsibility for Annual Reports as needed

§  Accessibility

§  Risk Management

§  Cultural Competency

§  Participant Follow Up Survey

§  Participant Satisfaction Survey

§  Employee Satisfaction Survey

§  Stakeholder Satisfaction Survey

§  Parent/Guardian Satisfaction Survey

§  Quality Management

§  Training

Assigned Responsibility for UMAR Plans

§  Risk Management Plan

§  Cultural Competency Plan

§  Accessibility Plan

§  Training Plan

§  Health and Safety Plan

§  Quality Management Plan

Development and Maintenance of Databases (includes, but is not limited to)

§  Training

§  Clinical Supervision Plans

§  Accessibility (only as information is provided)

§  Audits and Plans of Correction (only as information is provided)

Data Collection and Analysis of Surveys (and any other surveys or outcomes as needed)

§  Participant Satisfaction Survey

§  Stakeholder Satisfaction Survey

§  Employee Satisfaction Survey

§  Parent/Guardian Satisfaction Survey

§  Training Evaluations

§  Participant Follow Up Surveys

§  Incident/Accidents reported

§  Health & Safety inspection results

§  Management of training database – updating and forwarding to staff

Recording and Maintenance of Minutes (includes, but is not limited to)

§  Employee Advisory Committee

§  Manager’s Meeting

§  Residential Services Program Planning

§  Human Rights Committee

§  Health & Safety Committee

§  Board Meetings

§  Any other meetings as directed

 

Preferred and Minimum Position Qualifications:

Must have MH/IDD Clinical Qualified Professional status as sated by 10A NCAC 27G.0104.

The Quality Management Director must have training or education in performance improvement techniques as demonstrated by either: (1) A Bachelor’s Degree from an institution of higher learning accredited by an accrediting body recognized by the U. S. Department of Education in a field of health, behavioral health, rehabilitation, human services, human development, education, social sciences, criminal justice, administration, management, organizational development, information management, business, or a related field or discipline and three years of experience gathering and analyzing data for quality management, quality assurance or quality improvement for a health or human services provider agency, or an equivalent combination of training and experience; or (2) A Master’s Degree from an institution of higher learning accredited by an accrediting body recognized by the U. S. Department of Education, in a field of health, behavioral health, rehabilitation, human services, human development, education, social sciences, criminal justice, administration, management, organizational development, information management, business, or a related field or discipline and one year of experience gathering and analyzing data for quality management, quality assurance or quality improvement for a health or human services agency or an equivalent combination of training and experience.

• BS/BA required - 3years preferred in a Quality Management Analytical Role.

• Proficiency with spreadsheets, Word Processing, CC Mail, Excel, PowerPoint.

• Proven analytical/technical aptitude evidenced by 3 or more years of successful experience in a quantitative role (i. e., Quality Management, Risk Management,)

• Coaching, Mentoring, Teaching skills

• Excellent communication, presentation and facilitation skills

• Teamwork/collaborative style / able to maintain corporate confidentiality

• Demonstrated Project Management skills of group projects.

• Problem solving skills evidenced by demonstrated results in past positions

• Strong growth and performance potential

• Ability to work under tight deadlines and handle multiple/detail-oriented tasks.

• High level of computer literacy - proficient in developing spreadsheets (Excel preferred), and word processing. Current aptitude, or ability/interest to master, Access, PowerPoint. Must be knowledgeable of Survey Monkey, as a survey analysis tool.

• Change agent with the ability to influence at all levels of the organization.

• Strong business acumen, judgment, and maturity with the ability to differentiate strategic vs. non-strategic opportunities.

• Statistics experience, education or ability to learn.

• Orientation Process and Customer focus

 

Additional Job Requirements (Licenses, Certifications, Personal Vehicle, etc.)

§  Operate computer hardware/software.

§  Be able to communicate both orally and in writing.

§  Be able to stand for extended periods of time and deliver oral and visual training to groups of individuals.

§  Valid Drivers License and automobile insurance.

§  Have personal vehicle with valid tag, registration and licensure.

§  Travel will be required.

§  Have flexible hours and the ability to train during the day and evenings.

§  Maintain current instructor licensures and certifications as outlined in Essential Functions section

 

Essential Equipment Routinely Used In This Position:

Computer

Copier

Telephone

Fax

Driving Automobile

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

• While performing the duties of this job, the employee is regularly required to talk and hear.

• Employee frequently required using hands, reaching with hands and arms.

• The employee is occasionally required to stand, walk, sit, stoop, kneel, crouch or crawl.

• There are no specific vision abilities required by the job.

Work Environment:

The work environment characteristics described here are representative of those employees’ encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

While performing the duties of this job, the noise level in the work environment is a moderate noise level.

 

Employee Review and Signature:

Signatures:

This job description has been approved by all levels of management:

Manager______________________________________________________________________

HR Director___________________________________________________________________

Employee signature below constitutes employee’s understanding of the requirements, essential functions and duties of the position. Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Employee Signature/Date: _____________________________________________________________________________