Vice President, QEC

  • Hospice of the East Bay
  • Hospice Pleasant Hill California 94523 US
  • Posted: Jun 29, 2018
Other Nursing

Job Description

Position: VP, Quality, Education and Compliance


About Us


Hospice of the East Bay (HEB) is a community-based program of home care for terminally ill patients.  Care is given to patients and families by an interdisciplinary group.  Bereavement care is provided to the family for one year after the death.  Hospice services are given regardless of ability to pay, making the agency dependent on donations and insurance billing to meet operating expenses.


Our Employee Benefits


Hospice East Bay is committed to providing a comprehensive benefits and compensation package for our employees. Our health benefits include 100% employer-paid premiums for our high deductible medical plan offered with a Health Savings Plan partially employer funded for eligible employees.  Employer paid dental and vision premiums,  Additional benefits include generous paid time off program, educational assistance, and employer-matched contributions to our retirement plan (up to $2,000 annually), Life/AD&D coverage, a comprehensive Employee Assistance Program, and convenient discounts on many services, including gym memberships, dry cleaning, produce delivery, mobile phone service, and automotive care.


Position Summary


Reporting to the President and Chief Executive Officer, this position  manages the Quality, Education and Compliance Coordinators (QECs); Maintains administrative policies and procedures; Coordinates and oversees the Agency's Quality Assessment Performance Improvement(QAPI) Committee data collection and reporting; Leads preparation of Agency for CHAP accreditation, California Department of Public Health surveys and annual Kaiser site visits; Chairs the QAPI Committee, and functions as Patient Safety Officer; Attends Board of Directors meetings to present PI information on biannual basis or more frequently, as requested; Facilitates Board Quality and Safety Committee quarterly, working with Chairperson to coordinate agenda and minutes; Assumes role of Risk Manager,  working with Agency insurance carrier for any legal issues or claims against Agency; Agency resource for regulatory and accreditation standards questions and issues, Assumes role of Compliance Officer, responsible for the Agency Compliance Program, Staff education and enforcement; Assumes role of HIPAA Privacy Officer, working with HIPAA Security Officer (IT Director) in order to maintain confidentiality of medical information, and is the designated Safety Officer, responsible for staff safety, patient safety, emergency preparedness and facility safety.


Essential Functions:



·      Designs and oversees the staff education program using results of staff surveys, updates in regulations, information gathered in QAPI activities, Unusual Occurrence Reports and complaints, and with input from managers and physicians

·      Plans annual competency program for all disciplines and provides computer-based and hands-on skill validation

·      Oversees the administration of the HCI HEB University online learning programs for regulatory compliance with educational mandates

·      Facilitates completion of school contracts and acceptance of qualified students for clinical community-based hospice experience

·      Assures 12 hrs of HHA education is provided annually and tracks compliance


Administrative Manual

·      Updates Administrative Policy Manual with new and/or revised policies as changes in programs,        services and regulations occur;

·      Facilitates Agency policy approval for new and revised policies through Senior Leadership, QAPI and Board Quality and Safety Committees

·      Ensures old Administrative Policy Manual is archived electronically


Quality Improvement

·      Defines data elements, plans, prepares and leads the quarterly Quality Assessment Performance Improvement (QAPI) Committee meetings;

·      Monitors complaints received, analyzes for trends, and develops corrective action plan with clinical leaders as indicated

·      Facilitates quarterly comprehensive chart audits for all teams and programs, developing criteria to monitor compliance with regulations and past survey deficiencies.  Audit deficiencies are communicated to clinician and manager. 

·      Facilitates Utilization Management (UM) audits of all patients with length of stay > 180 days, and 10% of non-cancer diagnoses with stays < 180 days, with hospice eligibility issues reported directly to team managers and IDT

·      Tracks ongoing Agency Performance Improvement Projects (PIPS) and designates appropriate managers or staff to conduct performance improvement projects, based on QAPI and benchmarking data

·      Tracks serious adverse events, reports appropriately and develops corrective action plans, in conjunction with CEO, VPs and managers, if needed; and

·      Reports Agency QAPI statistics and activities to Board Quality and Safety Committee quarterly, and to EBIC Board semi-annually


Accreditation/Deemed Status Survey

·      Understands the requirements and process for Community Health Accreditation Program (CHAP) accreditation, assuring that all new CHAP requirements are implemented

·      Follows up on annual fees and application process for re-survey in a timely manner to assure that there is no lapse in the Agency's accreditation status

·      Completes tri-annual Self-Assessment, involving Senior Leadership and managers

·      Outlines a plan to prepare the agency for the accreditation survey, including staff education, which is approved by Senior Leadership

·      Assures that all staff, volunteers and the EBIC Board understands the survey process and their role during a survey

·      Acts as liaison with surveyor and assures that the surveyor has needed staff for interviews, field visits and other data as requested

·      Arranges for surveyor assistance with electronic medical record review

·      Assures plan of correction (DPH 2567 or CHAP electronic plan of correction) is completed and submitted in timely manner to surveying authority


New Employee Orientation

·         Designs/annually updates clinical classroom orientation program for new employees

·         Provides folder of skills checklists, sign-offs, orientation schedule (developed by direct supervisor), and evaluation forms to be completed during orientation period by orientees and mentor;

·      Provides hands on competency check-offs for mandatory skills;

·      Tracks completion of orientation requirements in collaboration with Human Resources Department


Infection Control

·      Supervises Infection Control program compliance with hospice regulations and CHAP Standards, designating Agency Infection Control Nurse

·      Tracks Agency-acquired patient infections and staff infections, as determined for QAPI program monitoring

·      Tracks and reports infection control data for internal and/or external benchmarking purposes

·      Assures staff education in infection control prevention annually

·      Notifies clinicians of Contra Costa/Alameda County flu shot mandates

·      Works with HR to calculate annual statistics for clinician and agency flu shot immunizations


Data Management/Benchmarking

·         Responsible for integrity of the Allscripts electronic medical record, with collaboration and delegation of duties, as appropriate, to the Informatics Nurse and Clinical Trainer

·         Oversees the data gathering and data entry process for OCS hospice benchmarking data submission quarterly

·         Oversees the administration and reporting of the NHPCO Family Evaluation Hospice Care (FEHC, through 2014), Hospice CAHPS (beginning 2015) and Family Evaluation of Bereavement (FEBS) surveys through contracted vendor

·         Reports Agency status of other CMS reports, including PEPPER, HIS data comparisons, and annual Referral Source Satisfaction survey


HIPAA Privacy/Security

·      As HIPAA Privacy Officer, investigates, analyzes and keeps records of potential breaches, including those electronic transmissions held by HEB encryption software

·      Monitors Recall medical record storage systems and processes, approving any destruction orders



·         As Compliance Officer, assures compliance plan includes all elements, compliance line is available for staff and patient reporting, investigates issues, and review of plan occurs annually by the Board

·         Responsible for Medicare processes and forms, including current Medicare ABNs, Patient Handbook, consents, financial responsibility


Position Requirements:

·         Demonstrated knowledge of State and Federal laws pertaining to hospice and home care programs

·         Demonstrated ability to communicate with all levels of hospice staff, including Board of Directors

·         Strong planning, analysis, problem solving and project management skills

·         Ability to design and implement effective staff education and training programs

·         Ability to work well with others, inspire confidence and respect and evidence strong moral character and ethical behavior

·         Knowledge of SNF and RCFE regulations in relationship to hospice and home health practice

·         Knowledge of CHAP regulations for hospice and home health

·         Clinical knowledge/expertise in management of hospice and home care programs; and knowledge of the Quality Assessment Performance Improvement (QAPI) process within a hospice and/or home health agency


Experience & Education:

·         Master's degree in a health related field or executive level experience required

·         Current California Registered Nurse (RN) License required

·         Three to five years' experience in hospice and/or home health setting