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• Participate in leadership meetings and cross-functional initiatives.
• Work collaboratively to resolve issues that impact patient care or agency operations.
• Ensure patient-related information is communicated appropriately and timely across departments.
• Serve as a senior operational resource for staff and other department leaders.
Incident & Complaint Management
• Oversee the timely review and resolution of patient incidents.
• Ensure appropriate documentation, investigation, escalation, and follow-up.
• Identify recurring issues and develop strategies to prevent repeat occurrences.
• Collaborate with Compliance, Coordination and leadership on serious or reportable incidents.
Quality Improvement & CQI
• Lead and coordinate the agency's Continuous Quality Improvement (CQI) program as it relates to patient services.
• Organize and facilitate regular CQI meetings, including preparation of agendas, review of performance data, identification of trends, and development of corrective action plans.
• Monitor CQI initiatives to ensure action items are assigned, completed, and sustained.
• Use patient complaints, incidents, survey results, service data, and other quality indicators to identify opportunities for improvement.
• Partner with Compliance and other department leaders to develop and implement quality improvement initiatives.
• Maintain appropriate documentation of CQI activities, findings, recommendations, and follow-up.
• Present relevant CQI findings and recommendations to senior leadership.
• Oversee the agency's annual patient satisfaction survey process from planning through completion and analysis.
• Serve as a primary point of responsibility for patient-related Department of Health complaints and required reports.
• Maintain organized records of complaints, investigations, corrective actions, and regulatory correspondence.
Aide Training & Certification Programs
• Oversee and manage agency training programs designed to prepare and certify aides in accordance with applicable regulatory and agency requirements.
• Ensure required aide training is delivered consistently and meets applicable regulatory standards.
• Coordinate instructors, training sessions, attendance, competency evaluations, and required documentation.
• Monitor aide completion of required training and certification milestones.
• Ensure training records are accurate, current, and available for regulatory and internal review.
• Evaluate training outcomes and identify areas where additional education or remediation is needed.
• Work with leadership and other departments to ensure training programs support agency staffing and operational needs.
• Develop and implement ongoing education and refresher training as appropriate.
• Ensure aides who do not meet required training or competency standards are identified and appropriately followed up with before providing services when required.
Regulatory Readiness
• Serve as primary point of contact for DOH and other governing authorities during surveys, audits and other reviews
• Maintain ongoing readiness by ensuring patient services documentation, policies, training records, CQI materials, complaint records, and required reports are maintained in an audit-ready manner.
• Develop and monitor corrective action plans resulting from regulatory findings.
• Ensure identified deficiencies are addressed within required timeframes and that corrective actions are sustained.
