Director of Performance Excellence (Quality & Compliance) - Hospice

Job Summary:

The Director of Performance Excellence is a key leadership position responsible for overseeing quality, compliance, education, emergency management, medical records, data management, infection control and policy and procedure compliance. This role ensures the delivery of exceptional patient care, operational efficiency, and regulatory compliance while fostering a culture of excellence and continuous improvement. The Director will provide strategic oversight, align initiatives with the organization’s mission and vision, and ensure adherence to the highest standards of hospice care.

Accountability:

Reports to the Chief Executive Officer 

Direct reports to this position:

Senior Analyst 

RN Clinical Quality Analyst

Hospice Training Specialist

FLSA Status: Exempt

Essential Duties and Responsibilities:

Quality and Performance Improvement

• Lead and manage quality improvement initiatives to ensure the organization meets or exceeds state, federal, and accrediting body standards
• Oversee the collection, analysis, and reporting of quality data, including Hospice Item Set (HIS), CAHPS scores, and other performance metrics
• Develop and implement performance improvement plans to address gaps in care, compliance, and patient outcomes
• Chair the Quality Assurance and Performance Improvement (QAPI) committee and provide regular updates to leadership on progress and outcomes
• Establish and monitor key performance indicators (KPIs) to drive excellence in care delivery and organizational operations
• Other duties as assigned

Compliance and Policy Management

•  Ensure the organization is compliant with all state, federal, and Medicare Conditions of Participation (CoPs) for hospice care
• Develop, update, and oversee compliance with organizational policies and procedures to reflect regulatory and operational standards
• Lead internal audits and prepare for external audits or surveys by accrediting bodies or regulatory agencies
• Investigate and resolve compliance concerns, reporting findings to appropriate leadership and agencies as required
• Other duties as assigned

Education and Staff Development Oversight

• Provide strategic oversight of the organization’s education programs to ensure staff are trained in compliance, quality, and best practices for hospice care
• Develop systems to track participation in education programs and ensure compliance with regulatory standards
• Collaborate with department leaders to identify education needs and implement targeted training initiatives to address gaps and promote staff development
• Other duties as assigned

Emergency Management

• Oversee the development and maintenance of the organization’s emergency preparedness plan, ensuring compliance with federal and state regulations
• Monitor the scheduling and execution of emergency drills and training to prepare staff for potential disasters or crises
• Collaborate with local and regional agencies to ensure effective communication and coordination during emergencies
• Conduct post-event analysis to improve the organization’s emergency response protocols
• Other duties as assigned

Medical Records Oversight

• Provide oversight of medical records management to ensure accuracy, completeness, and compliance with legal and regulatory requirements
• Monitor processes for secure storage, timely documentation completion, and access for authorized personnel
• Ensure periodic audits of medical records to align with quality and compliance standards
• Other duties as assigned

Infection Control

• Oversee the organization’s infection control program, ensuring compliance with state, federal, and accrediting body guidelines
• Monitor infection rates, identify trends, and implement prevention strategies
• Provide guidance on infection control policies and ensure staff receive appropriate training
• Other duties as assigned

Data Management

• Ensure the integrity and accuracy of data systems, supporting the collection and analysis of key performance metrics
• Oversee the development and maintenance of dashboards and reporting tools to provide actionable insights for leadership
• Collaborate with IT and operational teams to ensure data security and compliance with HIPAA regulations
• Utilize data to identify trends, monitor outcomes, and support strategic decision-making
• Other duties as assigned

Leadership and Collaboration

• Collaborate with the leadership team to align performance excellence initiatives with strategic goals and operational priorities
• Function as a liaison between clinical teams, administrative staff, and external stakeholders to foster a unified approach to quality and compliance
• Promote a culture of accountability, excellence, and continuous improvement throughout the organization
• Provide mentorship and leadership to department staff, foster engagement and professional development
• Other duties as assigned

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Skills and Abilities

1. Strong analytical and critical thinking skills, with the ability to interpret complex data and develop actionable plans
2. Exceptional organizational and time management skills, with the ability to prioritize and manage multiple projects
3. Excellent written and verbal communication skills to engage effectively with staff, leadership, and external stakeholders
4. Proficiency in quality management software, electronic medical records (EMR), and Microsoft Office Suite
5. Able to lead and inspire teams, fostering a culture of excellence and accountability.
6. Demonstrate ability to problem-solve and make decisions by assessing situations and considering all possibilities to resolve the issues, then correcting the problems presented in a reasonable amount of time
7. Seek guidance and direction as necessary utilizing proper chain of command
8. Demonstrate knowledge and respect of rights and responsibilities by observance of patient/participant: privacy, confidentiality, and safety, including reporting of patient/participant abuse or neglect
9. Demonstrate professionalism by respectful interpersonal relationships with team members, patients/participants and families, supervisors, and community members
10. Demonstrate knowledge of compliance with all agency policies and procedures
11. Demonstrate effective time management skills by coordinating activities to achieve maximum productivity and efficiency with a willingness to adjust or revise work schedules as necessary or requested
12. Complete assigned projects within specified time frames
13. Assume responsibility for on-going personal development and continuing education
14. Stay current with all mandatory agency requirements

General

1. Ensures organizational compliance with legal, regulatory and accreditation requirements
2. Adheres to patient rights, abuse reporting and confidentiality policies 
3. Fosters and maintains an effective working relationship between peers, professional staff, and other personnel
4. Participates in Performance Improvement activities
5. Demonstrates ability to problem-solve and make decisions
6. Demonstrates effective time management skills by coordinating activities to achieve maximum productivity and efficiency
7. Stays current with all mandatory agency and regulatory requirements
8. Adheres to company dress code, attendance, and code of conduct as outlined in the Employee Handbook

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Physical/Safety Requirements:

1. Participate appropriately in emergency procedures (including disaster drills) by following the designated plan of action in the event of an emergency
2. Operate equipment in a safe manner and shares responsibility for communicating safety violations or unsafe practices to management (equipment used is general office equipment including phone, copy machine, fax machine, etc.)
3. Category 2 for potential exposure to blood/body fluids. (Does not usually require the performance of procedures or other tasks in the work routine that involve exposure to blood, body fluids or tissues, but Category 2 tasks may require the unexpected performance of these procedures)
4. Utilize appropriate PPE as needed
5. Must be able to lift 10-25lbs. occasionally
6. Must be able to move intermittently throughout the workday
7. Must have the strength and endurance required for sitting for lengthy periods of time
8. Use appropriate body mechanics as needed 
9. The individual may be required to drive to meetings with clients, health care professionals and patients’ homes
10. The noise level in the work environment is usually minimal

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. 

In compliance with the Americans with Disabilities Act of 1990, the employer will provide reasonable accommodations to meet the work environmental and physical demands listed above.

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Qualifications and Experience:

1. Bachelor’s degree in nursing, Healthcare Administration, or a related field required; master’s degree preferred
2. Minimum of 5 years of progressive leadership experience in hospice or healthcare quality, compliance, or education
3. In-depth knowledge of hospice regulations, including Medicare Conditions of Participation (CoPs), HIS, and CAHPS reporting preferred
4. Demonstrated experience in leading quality improvement and compliance initiatives
5. Primarily office-based with periodic travel, audits, and quality improvement initiatives
6. Must be available for occasional evening or weekend work to support organizational needs or respond to emergencies
7. Must have reliable transportation, a valid driver’s license, and current auto insurance
8. Successful completion of a background check pursuant to NRS 449.188 and NRS 179A.100 along with a pre-employment drug screen and physical, TB testing, previous employment and reference checking, and an MVR (may include verification of education) 
9. Must read, speak, write, and understand the English language
10. Must be able to handle frequent interruptions, problem solve and have excellent follow through skills
11. Must be able to cope with emotionally charged situations encompassing patients, families, and other caregivers 
12. Able to delegate and oversee staff effectively to maintain compliance etc., within the organization

Certifications

• Certified Public Health Quality (CPHQ) preferred
• Certified Six Sigma Black Belt preferred

Performance Metrics

• Achieving targeted quality and compliance benchmarks, including HIS and CAHPS scores
• Completion of regulatory audits with no deficiencies
• Timely and accurate completion of education program participation and compliance tracking
• Maintenance of accurate and compliant medical records
• Effective infection control program implementation and monitoring