Director of Quality Improvement

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Brief Job Description:

The Director III, Director of Quality Improvement directs and oversees state-office management support for the organization, operation and business functions of quality assurance and improvement processes for the thirteen (13) SSLCs to facilitate quality of services, consistency, and ensure execution of the Associate Commissioner’s goals and vision for the SSLC. Establishes a strategic plan and develops and ensures the implementation of state-wide operational policies, procedures, and guidelines which govern quality assurance systems in the clinical areas of medical, psychiatry, dental, pharmacy, nursing, qualified intellectual disability professional services (QIDP), behavioral health and habilitation therapies and program including active treatment.  Directs, promotes and models an interdisciplinary approach. Serves as a subject matter expert and oversees others who serve as subject matter experts for ICF-IID regulations applicable to SSLCs, best practices, and clinical standards.  Monitors, assesses, and oversees quality of clinical and program services and interdisciplinary collaboration; and directs the remediation of service delivery issues.  Provides leadership and strategic direction to and establishes goals and objectives for quality improvement and quality assurance staff.  Performs managerial functions to oversee their work.  Directs and oversees provision of training and technical assistance to state office and SSLCs to comply with ICF-IID regulations and quality assurance and improvement best practices. Develops and implements monitoring tools. Participates as a member of and oversees the work of team members who coordinate, lead, and participate on the state review team. Takes actions based on results and makes recommendations to the Associate Commissioner, Director of Operations and SSLC Directors regarding the need for systemic changes. Oversees preparation of reviews and analyzes required reports. Represents the agency before various groups and works effectively with state and local officials, community leaders, and the media, as assigned.  Serves as a member of the SSLC Executive Leadership Team.  Serves on and/or directs the work of committees and workgroups.  Promotes positive working relationships with outside agencies and with other SSLC departments. Works under minimal supervision, with extensive latitude for the use of initiative and independent judgment. Travel is required up to 20% of the work schedule.

Essential Job Functions (EJFs):

[Attends work on a regular basis and may be required to work a specific shift schedule or, at times, even a rotating schedule, extended shift and/or overtime in accordance with agency leave policy and performs other duties as assigned. Serves in the SSLC on-call rotation as assigned.

Serves as a member of the SSLC executive leadership team. Directs and oversees state-office management support of the organization, operation, and business functions for quality assurance improvement processes for the thirteen (13) SSLCs to facilitate continuous system-wide improvement processes and ensure execution of the Associate Commissioner’s goals and vision for the SSLC. Establishes a strategic plan for the assigned area in accordance with standards set out by HHSC and the SSLC division including goals and objectives for innovative and effective improvement in delivery of services at the SSLCs.  Establishes processes which facilitate accountability and provide meaningful feedback to stakeholders on progress toward the achievement of goals and objectives.  Develops and ensures the implementation of state-wide operational policies, procedures, and guidelines which govern quality assurance and improvement.  Directs, promotes, and models a data-informed approach to quality assurance and improvement. (15%)

Serves as a subject matter expert and oversees others who serve as subject matter experts for ICF-IID regulations applicable to SSLCs, best practices, and data and trend analysis.  Ensures oversight of the techniques being used to evaluate SSLC programs such that they continuously improve the quality of services and ensure the health, safety, care, and other services provided by each facility meet the needs of consumers and reflects professionally accepted standards of practice.   Advises the Director of Operations on the quality of programs and services provided; and makes recommendations for effective and efficient use of resources.  Monitors, assesses, and oversees quantity and quality of data collection and analysis; and directs the remediation of service delivery issues through plans of improvement and corrective action plans. (15%)

Provides leadership and strategic direction to staff in assigned area including quality assurance specialists, survey coordinator, data analysts, quality assurance manager and compliance manager.  Performs managerial functions including hiring, assigning work, completing performance evaluations, recommending personnel and disciplinary actions, and overseeing the work performed staff.  Uses leadership and teambuilding skills to motivate staff to work toward common objectives and goals.  Oversees allocation of staff resources, directing focus on specific areas of need across the SSLCs. Assists local SSLC leadership with hiring decisions for quality assurance and data analyst positions to ensure quality and consistency. (15%)

Establishes the goals and objectives for each of the assigned staff to align with the Associate Commissioner’s vision and to ensure program and services conform to relevant state and federal laws, rules, and regulations, and best practices.  Develops and oversees standards for achieving the established goals including short and long-term planning, facilitates accountability, collaboration, integration and support to SSLCs.  Directs collaboration between assigned staff and other state-office disciplines and SSLC leadership.   (10%)

Directs and oversees provision of training and technical assistance to state office and SSLCs to comply with ICF-IID regulations and best practices, including the results of state regulatory reviews. Establishes and monitors processes which facilitate accountability and provide meaningful, objective feedback to all stakeholders on progress toward the achievement of those objectives and goals, including leading the state review team Participates as a member of and oversees the work of team members who coordinate, lead, and participate on the state review team.  Maintains a physical presence at each of the SSLCs by traveling in person to the state reviews. Uses data to provide feedback on performance and drive decision making.  Directs the development and implementation of Corrective Action Plans (CAPs), Quality Improvement Plans (QIPs) and Plans of Improvement (POI), including overseeing the establishment of goals and objectives for the plans, developing and approving schedules for work completion, setting priorities, and standards for achieving goals.  Directs CAP and QIP evaluation activities performed by assigned staff. (10%)

Directs and oversees the development and implementation of tools which monitor services such as Quality Service Review (QSR) tools. Takes actions based on results, including revising monitoring tools when necessary. Serves as a liaison to the independent monitor for the SSLCs, which includes coordinating regular on-site reviews and serving as the program contact for the contract. Makes recommendations to the Associate Commissioner, Director of Operations, and SSLC Directors regarding the need for systemic changes such as to staffing structure, quality assurance practices, and training/development based on results of reviews. (10%)

Leads the preparation of reviews and analyzes required reports such as statewide Quality Assurance/Quality Improvement (QA/QI) Council reports, mortality review committee reports, external mortality review reports, and monthly SSLC-specific trend reports. Serves as a liaison to the external mortality review organization for the SSLCs, which includes coordinating activities and serving as the program contact for the contract. Leads, oversees, and analyzes the preparation of reports to ensure all pertinent information is present and accurate prior to submission to HHSC leadership to ensure adequacy and usefulness of information. (10%)

Oversees systems for, and serves as key contact staff, providing aggregate data and information to advocates, judicial representatives, legislators, and the Department of State Health Services (DSHS) on programs and services. Responds to requests for information and participates in strategic communication efforts.  Provides requested information to SSLC executive leadership for incorporation into agency documentation exceptional item requests/Legislative Appropriation Requests (LAR).  Responds or oversees response to Open Record Requests and legislative inquiries, as assigned.  Reviews and analyzes proposed legislation to identify potential impacts to SSLC operations and advises the Associate Commissioner on strategies to implement new legislative directives. Works closely with Legal and stakeholders as needed.  Develops and/or oversees communication to internal and external partners such as those that communicate changes to expectations or new policies and procedures. (5%)

Represents the agency before various groups and works effectively with state and local officials, community leaders, and the media, as assigned.  Makes presentations, provides information, or testifies to legislative offices or committees, other state and federal agencies, stakeholders, and other organizations regarding division programs and services, as assigned.  Serves as a member of the SSLC Executive Leadership Team.  Serves on and/or directs the work of committees and workgroups including state-office QA/QI Council, mortality review team, state reviewer team, and other special projects aimed at increasing or improving clinical services, as assigned.  Promotes positive working relationships with outside agencies such as Provider Investigations (PI), Office of Inspector General (OIG), Local Intellectual & Developmental Disability Authorities (LIDDAs), and with other departments. (5%)

Other duties as assigned include, but are not limited to, actively participating and/or serving in a supporting role to meet the agency’s obligations for disaster response and/or recovery or Continuity of Operations (COOP) activation. Such participation may require an alternate work schedule and/or location. (5%)

Knowledge, Skills and Abilities (KSAs):

Knowledge of management principles and techniques.

Knowledge of state and federal laws, regulations, policies, rules and requirements affecting programs and services.

Knowledge of the legislative process.

Knowledge of program evaluation and monitoring.

Knowledge of clinical services, treatment, training and supports for individuals with intellectual and developmental disabilities.

Knowledge of best practices in quality assurance and improvement.    

Skill in the analysis of complex information and data.

Skill in management of staff.

Skill in communications, working with people, negotiating among multiple parties, resolving conflicts, and establishing and maintaining effective working relationships with internal and external, public and private entities.

Skill in establishing, implementing, interpreting and communicating policies and procedures.

Skill in using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems.

Skill in the use of computers and agency/facility software including but not limited to Microsoft Word, Excel, PowerPoint, Access, and SharePoint.

Ability to develop and implement organizational vision to improve services provided and program performance.

Ability to identify problems, evaluate alternatives, and implement effective solutions.

Ability to provide oversight and direction to a service delivery system located in various locations across the state and possess the capability of determining when to apply uniformity or variance in management strategies based upon the unique needs of each facility.

Ability to establish goals and objectives and to devise solutions to administrative problems.

Ability to prepare comprehensive, concise and accurate reports; and to communicate effectively.

Ability to plan, assign, and supervise the work of others.

Ability to analyze and solve complex problems and to make effective decisions affecting the overall operation of a large organization.

Registrations, Licensure Requirements or Certifications:

N/A

Initial Screening Criteria:

• Bachelor's degree from an accredited college or university; and
• At least five (5) five years of experience in the administration, management, and productivity improvement in the human service delivery field (e.g., mental illness, intellectual and developmental disability, etc.) of a large organization or department.

• -OR-
• Master’s degree from an accredited college or university; and
• At least three (3) years of experience in the administration, management, and productivity improvement in the human service delivery field (e.g., mental illness, intellectual and developmental disability, etc.) of a large organization or department.

AND the following:

• Experience in ensuring the provision of quality services, treatment, training and supports for individuals with intellectual and developmental disabilities.
• Experience coordinating quality improvement activities.
• Experience in policy development.
• Experience in data analysis. 

Additional Information:

Applicants must pass a fingerprint criminal background check, pre-employment drug screen, and registry checks including the Client Abuse/Neglect Reporting System (CANRS), Nurse Aide, Medication Aide and Employee Misconduct and HHS OIG List of Excluded Individuals/ Entities.  Males between the ages of 18 – 25 must be registered with the Selective Service.

All State Supported Living Center employees are subject to Random Drug Testing.

Flexibility in work hours may be required for this position. The position may be required to work overtime and/or extended hours.

All applicants must be at least 18 years of age to be considered for employment at a state-operated facility.

Review our Tips for Success when applying for jobs at DFPS, DSHS and HHSC.

Active Duty, Military, Reservists, Guardsmen, and Veterans:

Military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position may include, but not limited to those listed in this posting. All active-duty military, reservists, guardsmen, and veterans are encouraged to apply if qualified to fill this position. For more information please see the Texas State Auditor’s Job Descriptions, Military Crosswalk and Military Crosswalk Guide at Texas State Auditor's Office - Job Descriptions.

ADA Accommodations:

In compliance with the Americans with Disabilities Act (ADA), HHSC and DSHS agencies will provide reasonable accommodation during the hiring and selection process for qualified individuals with a disability. If you need assistance completing the on-line application, contact the HHS Employee Service Center at 1-888-894-4747. If you are contacted for an interview and need accommodation to participate in the interview process, please notify the person scheduling the interview.

Pre-Employment Checks and Work Eligibility:

Depending on the program area and position requirements, applicants selected for hire may be required to pass background and other due diligence checks.

HHSC uses E-Verify. You must bring your I-9 documentation with you on your first day of work. Download the I-9 Form

Telework Disclaimer:

This position may be eligible for telework.  Please note, all HHS positions are subject to state and agency telework policies in addition to the discretion of the direct supervisor and business needs.