VISITING NURSE SERVICE AND HOSPICE OF SUFFOLK: Director of Performance Improvement and Education (Full Time)

General Information
Location  505 MAIN STREET
United States
Employee Type  Exempt

Director of Performance Improvement and Education


Position Summary:  The Director of Performance Improvement and Education is responsible for the oversight of performance improvement and education activities at Visiting Nurse Service & Hospice of Suffolk, Inc. The Director of Performance Improvement also serves as the agencies Compliance Officer.


Duties and Responsibilities:

1. Collaborates with the Director of Clinical Operations in the integration of PI and Education into clinical services:

  • Implements a care management model directed at standardizing clinical practice using best practice concepts, improving clinical outcomes, and managing agency resources.
  • Provides education in the development of  OASIS integration and its impact on patient care and agency function.
  • Coordinates the documentation requirements of the Agency with the Clinical Managers.
  • Focuses on areas of improvement as delineated in OBQI/OBQM reports, benchmarks for the CHHA.
  • Focuses on areas of improvement for the Hospice Program.

2. Collaborates with the Hospice Director of Clinical Operations in the integration of PI and Education into clinical services.

3. Serves as the agencies Compliance Officer (see Compliance Officer job description).

4. Develops and modifies standards of care and expected outcomes in cooperation with Director of Clinical Operations by:

  • Ongoing updating of nursing care policies consistent with sound nursing practice with approval from the Medical Advisory Board.
  • Participation in administrative and supervisory meetings for the exchange of information and ideas.
  • Orientation of new staff regarding established standards and outcomes.
  • Participates in budgetary planning for the agency.

5.Monitors and oversee compliance with regulations as measured by:

  • Utilization Review/Quality Assurance Committee meetings conducted as required by New York State Health Department for Certified Home Health Agency and Certified Hospice.
  • CHAP accreditation guidelines and implementation of CHAP standards.
  • New York State Health Department regulations and Medicare Conditions of Participation.
  • Participation in committees to improve agency outcomes and utilization.
  • Consultations with supervisory staff and/or through home visits to patients

6. Oversees and has responsibilities for the performance improvement activities within the agency and the integration of these into practice:

  • Oversees documentation requirements for the agency in regards to best practices and timeliness, including accurate use of ICD- 9 coding regulations.
  • Focuses on areas of improvement as delineated in OBQI, OBQM reports, benchmarks per industry standards, for both the Hospice and the Certified Home Health Agency.
  • Conducts OASIS integrity Reports for the CHHA.
  • Monitors and evaluates VNSHS CHHA and Hospice program for ongoing relevancy, quality, and appropriateness, included in the annual agency evaluation.
  • Maintains liaison with other community agencies, including participation on other Professional Advisory Committees.
  • Analyzes data, investigates outliers and reports to appropriate person.
  • Identifies need for PI committees to improve problematic areas.
  • Maintains current PI plan to  meet CHAP requirements.
  • Chairs the PI Committee meetings, prepares findings for reporting and assists in future planning.

7. Functions as agency’s privacy officer ensuring agency compliance with HIPAA.

  • Develops and maintains policies and procedures required by the privacy rule.
  • Ensures that policies and procedures are implemented appropriately.
  • Follows up on all complaints and ensures documentation reflects any sanctions and or disciplinary action taken.
  • Ensure that all staff are educated and kept up to date regarding the privacy rule and any subsequent changes, in coordination with the Director of PI and Education.
    • Ensures that requests for PHI required by law are entered into the patients record. These include:
    • Public Health Activities:  Given to a public health authority to prevent or control disease.
    • Abuse, Neglect or Domestic Violence.
    • Requests from a Coroner or Medical Examiner.
    • Requests from a Funeral Director.
    • Subpoenas or Requests for Discovery.
    • Compliance with Worker’s Compensation Laws.
    • Oversight Activities Authorized by Law: Inspection of records by regulatory agencies.
    • Responds to patient’s request for accounting of disclosures.
    • Responds to patient’s request for copies of records and or amendments to them.

8. Designation as contact and response to Medicare, Medicaid, and other third party payers related to coverage issues of clinical services such as those that occur with Medicare Focused Reviews, Medicare appeals, and IPRO appeals.

9. Investigation of complaints and coordination with Director of Performance Improvement and Education for appropriate resolution and follow-up, including response to complainant and documentation of any sanctions and/or disciplinary action taken.

10. Conduct annual review and maintain VNSHS policy book in conjunction with the Director of Operations, to be current and disseminated appropriately to staff, including but not limited to the following:

  • Periodic and ongoing gathering of recommendations for change from management staff.
  • Preparation of proposed revisions to be presented for approval.
  • Presentation of proposed revisions for PAC and Board approval.
  • Presentation of approved changes to staff either directly or in cooperation with management staff.

11. Conduct Annual Agency Evaluation to encompass CHHA and Hospice programs, in coordination with the Director of PI and Education, the Director of Clinical Operations, and the Hospice Clinical Manager.

12. Review and respond to all requests for copies of clinical documentation, and record if needed as requests for PHI referenced in item #2 above, including but not limited to:

  • Subpoenas and Requests for Discovery.
  • Requests from a Coroner, Medical Examiner, or Funeral Director.
  • Requests from regulatory agencies.
  • Requests from third party payers including Medicare and Medicaid.
  • Response to patient requests for medical record.
  • ADRs from Medicare.

13. Attend or participate in web seminars presented by regulatory bodies, membership organizations, or related organizations through which regulatory or industry trends are communicated.

14. Establishes a committee to assist in defining the educational needs of the agency, and coordinates and oversees the Staff Education Coordinator in meeting the educational needs of  the agency.

15. Provides direct supervision of:

  • Care Manager
  • PI and Education Coordinators
  • Staff Development Coordinator
  • PI Clerical
  • ICD-9 Coder

16. Employee adheres to all applicable federal, state, local laws and regulations.

17. Other duties as assigned.


Physical/Cognitive Requirements:

  • Physical agility in the form of being able to ambulate, drive a motor vehicle, and negotiate stairs.  Vision acuity correctable to normal with normal color perception.  Hearing acuity correctable to normal.  Acute sense of smell for normal perception.  Ability to verbalize so that the average person can comprehend.




  • Registered Professional Nurse currently licensed in New York State.
  • Bachelors Degree in Nursing or other health related field from an accredited college or university. 
  • Masters degree preferred.
  • Demonstrates leadership and decision making abilities
  • Committed to the provision of quality care.
  • Familiar with home care and its implementation.
  • Skilled communicator.
  • Flexible, innovative, and autonomous professional
  • Minimum of two years experience in a supervisory capacity in a Certified Home Health Agency OR 2 years of home care nursing experience, plus a master degree in nursing, public health, business administration or another health related field.      



Visiting Nurse Service and Hospice of Suffolk offers a rich benefits package and a competitive salary. EOE