Regional LTAC Director of Clinical and Quality

The Regional LTAC Director of Clinical and Quality oversees framework and strategy of the quality and clinical programs of a network of LTAC hospitals.

The Director of Clinical Services and Quality participates in decision making, policy determination, and the planning and operations of the facility based division.

This position has the authority and responsibility for establishing and enforcing standards of patient care, patient care policies and procedures, and standards of nursing practice.

This position is accountable for overall management and coordination of an integrated performance improvement program and on-going preparation for regulatory surveys for assigned facilities. 

LHC Group is the preferred post-acute care partner for hospitals, physicians and families nationwide.

From home health and hospice care to long-term acute care and community-based services, we deliver high-quality, cost-effective care that empowers patients to manage their health at home.

More than 60 leading hospitals and health systems around the country have partnered with LHC Group to deliver patient-centered care in the home.

More hospitals, physicians and families choose LHC Group, because we are united by a single, shared purpose: Its all about helping people.

Essential Functions

• Supervises and mentors the Facility Based Clinical and Quality Home Office Facility Based Staff.

• Serves as a liaison, resource, and/or educator for Infection Control/Employee Health issues to ensure Infection Control/Employee Health/Quality Assurance Programs are implemented and managed appropriately.

• Assess practices and policies for infection control and employee health.

Recommends changes or modifications as needed to improve outcomes or maintain compliance with CDC measures and regulatory/accreditation agencies.

• Collaborates with other disciplines, as appropriate, in the development of all policies and procedures as evidenced by seeking input and recommendations from department managers, medical staff, and legal counsel as necessary.

• Maintains compliance with the State Nurse Practice Act, OSHA guidelines, Medicare Conditions of Participation, Hospital Licensing Standards, and other regulatory bodies as applicable.

• Ensures clinical policies and procedures, processes, and documentation tools are in compliance with regulations and standards of practice, and ensures review of policies, procedures, and forms occurs on an annual basis.

• Ensures uniform delivery of clinical services provided throughout LHC Group facility based division.

Ensures appropriate direction, management, and leadership of all clinical service as evidenced by review of each hospitals performance improvement/quality assessment/safety risk/infection control reports on a quarterly basis.

• Ensures framework for clinical orientation and competencies are available for hospital leadership to utilize with their clinical staff on hire and on an annual basis.

• Ensures systems are in place to promote the integration of services to support the patients continuum of care as evidenced by assuring adequate education on resource management and discharge planning process as needed with new case managers.

• Evaluates clinical services to ensure quality of patient care and to mobilize resources and intervene as necessary to achieve expected goals and desired clinical outcomes on a daily basis.

• Recommend, support, and participate in educational services, programs of education and training, including orientation of new employees.

Encourage and facilitate the professional advancement of employees by affording opportunities for further education and experience as needed.

• Maintains effective communication and working relationships with Administration, Board of Directors, Medical Staff, Department Managers, and other personnel of LHC Group Facility Based Division through phone, email, and in person meetings on a constant basis.

• Works closely with other LHC departments to identify opportunities for improvement and mitigate compliance and risk issues.

• Facilitates the development of any required revisions in the quality improvement program per CMS changes and updates.

• Oversees facility PI projects identified through the on-going data driven quality assessments and performance improvement programs.

• Guides the interpretation and use of patient|family perception of care data, assisting in the development of initiatives to improve quality of care.

• Keeps abreast of state and federal regulatory requirements and coordinates education for PI principles and regulatory standards within the facility based division, when indicated.

• Monitors incident reports for potential patient care related risk and opportunities for improvement, and assist facilities with root cause analysis and incident investigation, when warranted.

• Supervises the training of new managers in clinical, case management, quality, infection control, CMS mandatory quality measures, patient perception of care survey administration and reporting functions.

• Ensures survey readiness assessments are performed at each facility at least annually and oversees corrective action plan to ensure continued survey readiness.

• Supervises and monitors the CMS Mandatory Quality Measures entry, and submission to ensure compliance to mandatory quality submission timelines.

• Oversees survey readiness, intra-cycle and post survey required activities, including correction action plan development and monitoring, in collaboration with the facility.

• Supervises and monitors the inter-rater reliability audits for CMS Mandatory Quality Measures.

• Performs other assigned duties timely and adequately.

Education & Experience

• Graduate of an accredited school of nursing as a Registered Nurse

• Bachelors Degree

• Masters preferred

• Minimum of 5 years of experience in nursing management

• Minimum of 3 years of experience in Infection Control and Performance Improvement

• Certification in HealthCare Quality, preferred

• Certification in Infection Control, preferred

• Able to demonstrate leadership and managerial ability, able to develop good interpersonal relationships and to utilize sound administrative principles.

• Understanding of CMS Conditions of Participation and all applicable regulatory and practice standards for hospitals.

• Effective written and verbal communication skills.

• Proficient computer skills with knowledge of Microsoft office, Excel, and data analytics.

• Goal-oriented and ability to affect change.

Equal Opportunity Employer – vets, disability.