Director of Quality and Performance Enhancement

Atlanta, Georgia
May 14, 2021
Jun 01, 2021
Position Type
Full Time
Degree Level
Experience Level


The Director of Quality and Performance Enhancement is responsible for developing, implementing and maintaining all quality, performance enhancement and outcome measurement systems within Programs and Administration in accordance with internal and external regulatory bodies.  Responsibility for all preparation work for the agency accreditation and ongoing monitoring to ensure compliance with accreditation in all areas. Coordinate the flow of information across departments to support this work. Works cooperatively with all administrative and program management staff to ensure regulatory compliance and the integrity of administrative and program policies, case files, support plans and related documentation.  Ensure the electronic clinical record is capturing information. Supports the Chief Operating Officer, CFO, and the Vice President of Development in areas of quality assurance. Involved in all facets of CQI and will work closely with program staff, compliance/QA staff, grants staff in the management and planning of CQI initiatives. A strong passion for continuous improvement both personal and organizational.  

Essential Functions:  

COA Reaccreditation

  • Ensures successful reaccreditation of the organization
  • Ensures ongoing compliance with accreditation standards

Quality and Performance Enhancement

  • Oversees and manages the Quality Assurance programs of the organization;
  • Works with clinical staff, managers, directors, and administration to ensure goals are met in accordance with the organization’s strategic work plan; provide management, staff, BOD, and other stakeholder groups with information regarding quality improvement efforts and make recommendations for improvement;
  • Assures the implementation of and monitoring of an organizational data warehouse; supports staff in making sure database(s) are being used effectively for data collection and monitoring;
  • Collects, reviews, and analyzes data to assess organizational performance across the organization to ensure employees meet department standards, grant and contract requirements; for example:
    • conduct randomized regular client file reviews for all program areas to ensure the standards set by governing authorities are met and is in compliance
    • performs chart reviews in response to major, unusual incidents to identify any performance or quality issues
    • reviews staff performance to ensure compliance with policies and procedures as required by the senior management team and/or department managers
  • Develops, plans and leads focused program and administration reviews; includes designing the review, creating review tools, establishing timelines, assigning reviews, securing department manager or senior leader support, performing data analysis and presenting final report; prepares reports on findings according to department standards for department managers and senior management team; tailors reports as needed to fit a wide variety of audiences
  • Chairs an agency wide Quality Improvement committee including those involving consumers, care givers and/or Inspiritus staff
  • Participates on Critical Incident Review Team
  • Supports quality improvement initiatives by identifying best practices and areas for improvement, performing root cause analysis, and working with the program manager/director within the organization to develop quality improvement and risk mitigation plans; identifies metrics to reassess performance
  • Confers with Accounting/Finance, Human Resources and Information Technology (Providyn) regarding procedural issues, policies, procedures, and specific concerns related to service utilization, quality assurance, quality improvement and risk mitigation
  • Coordinates QA evaluation of services (record review, observation, and interview); reports on QA evaluations semi-annually as an accompaniment to the QA work plan summary, PQI and COA accreditation process
  • Oversees and guides the development of policies and procedures that guide service delivery and data collection in accordance with Council of Accreditation (COA) as needed
  • Oversees program manuals that link service delivery to our client databases

Licensing, Permits and Corporate

  • Ensures certificates from licensing agencies are updated and posted properly
  • Ensures  all locations have the required insurance and business permits

Operations Management and Program Systems

  • Maintains Inspiritus Operations Management System where administrative and program specific policies and procedures manuals are located. Assembles and reviews all existing Inspiritus policies and procedures; insures that Inspiritus policies and procedures do not conflict with policies and procedures required by the State of Georgia or the Federal government
  • Responsible for development and ongoing outcomes management system
  • Maintains Extended Reach and Therap databases and works with program subject matter experts to make changes as required.
  • Conforms with, and abides by, all regulations, policies, work procedures and instructions

Contracts and Grants Compliance & Risk Management

  • Works with COO and program staff on pre-award planning
  • Oversees post award routing and reviews prior to signature by the CEO or COO
  • Ensures QA grant compliance and works collaboratively with programs to meet contractual reporting requirements
  • Reviews contracts for risk management
  • Develops and implements Inspiritus’ risk management plan. Updates as needed.
  • Procures and manages the Agency’s business insurance policies including property, automobile, liability, worker’s compensation, etc. with the CFAO
  • Monitors the implementation of contracts, agreements and leases and assures compliance with all contract requirements;
  • Serves as Inspiritus’ Privacy Officer.
  • Directly responsible for meeting and maintaining the COA risk prevention and management requirements.

Non-Essential Responsibilities:  

  • Performs other duties as assigned to meet program needs.

Supervisory Responsibilities:

  • Responsibility for supervising Performance and Compliance Manager

Financial Responsibilities:

  • May manage funds and other Inspiritus assets, and does so in a manner that is considered productive, and conforms to approved budgets. 

Minimum Qualifications:

  • Master Degree in Business Administration, Education, Social Work, or Public Administration;
  • Minimum of 5 years of recent, relevant, senior-level business (preferably nonprofit/public sector) leader experience as an effective, professional in an organization with a multimillion dollar operational budget;
  • Demonstrated successful experience and performance in cultivating community relationships;
  • Experienced strategic planner
  • Effective verbal and written communicator with all persons in a culturally competent manner
  • Experience supervising a staff. Demonstrated ability to work collaboratively with others
  • Intermediate level computer skills including MS Excel, Word, Outlook, Power Point
  • Knowledge of information management systems and use of modern technology;
  • Or an equivalent combination of education and experience that enables successful performance of the essential functions of the job.
  • Must own a personal vehicle and have a good driving record and required automobile insurance

Desired Qualifications:

  • Experience with governmental contracts, social services, international persons, organizational development, leadership, and systems is preferred
  • Understands trends in social services and advocates for responsible public policy addressing issues affecting the quality of life in Georgia, particularly the poor, children and families at risk, the elderly, refugees, and other vulnerable populations;
  •  Case management or other relational data base software experience;
  • *Financial and/or legal background;
  • Knowledge of the social service environment in Georgia.

Physical Demands:

  • Regularly required to talk and hear
  • Required to stand, walk, sit, use hand to finger, handle or feel objects, tools or controls: and reach with hands and arms
  • Required to drive a personal vehicle
  • Specific vision abilities required by this job include close vision and the ability to adjust focus

Working Conditions:

  • While performing the responsibilities of this job, the employee travels by automobile and is exposed to changing weather conditions.
  • Occasional travel to organization-wide offices and relevant continuing education opportunities required

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