Manager of Quality & Compliance

Reporting to the Executive Director, the Manager of Quality & Compliance works collaboratively with the directors, managers, and team members at Humber Meadows Long Term Care Home (HMLTCH). Responsible for developing, implementing, and overseeing quality improvement initiatives that enhance the overall effectiveness of resident care and quality of life. Leading a variety of committees, coordinating the homes quality and risk management program, and managing interdepartmental audits for effectiveness, while ensuring continuous quality improvement. The Manager of Quality & Compliance will also ensure resolution of all compliance related issues, and the oversight of all required program committee meetings.

• Supports the implementation, maintenance and improvement of the organization’s quality management, quality improvement, safety and risk management program(s) and framework(s)
• Develops, implements, and maintains documentation, tools and resources needed to support the organization’s quality management, quality improvement, safety and risk management program(s) and framework(s)
• Provides formal and informal coaching, mentoring, teaching and advice to the organization and individuals within the organization on patient relations, quality management, quality improvement, safety, and risk management in general or in relation to the organization’s applicable program(s) and/or framework(s)
• Supports and/or leads the design, planning and execution of assigned improvement projects in collaboration with Quality & Risk team members and/or colleagues in other departments as needed.
• Responsible for the coordination of the BPSO at the home, as well as oversight on champion education, support, and evaluation.
• Responsible for CIHI documentation review.
• Responsible for the preparation, review, and evaluation of the required homes QIP, as well as submission and posting in line with all regulatory requirements.
• Supports, co-ordinates and/or leads the collection, reporting and/or analysis of quality, safety and/or risk data and information in assigned areas.

Quality Improvement Planning:

• Develop and implement a comprehensive Quality Improvement Plan.
• Collaborate with interdisciplinary teams to identify areas for improvement and establish measurable goals.
• Coordinate the annual satisfaction survey for team members, residents, and families.

Data Analysis and Reporting:

• Analyze data related to clinical outcomes, resident satisfaction, and other relevant metrics to identify trends and opportunities for improvement.
• Prepare regular reports for management, highlighting key performance indicators and progress towards improvement goals.

Training and Education:

• Provide training and education to staff on quality improvement methodologies, best practices, and regulatory requirements.
• Foster a culture of continuous learning and improvement throughout the organization.

Process Improvement:

• Lead process improvement initiatives to enhance the efficiency and effectiveness of care delivery processes.
• Collaborate with cross-functional teams to implement and monitor changes.
• Facilitate annual program evaluation process.

Risk Management:

• Identify potential risks, assess their impact on organizational objectives, and develop robust strategies to effectively manage and mitigate them.

Compliance and Auditing:

• Ensure compliance with regulatory requirements related to long-term care.
• Develop policies related to best practices, quality, risk, and all associated responsibilities.
• Conduct regular audits and assessments to identify areas of non-compliance and implement corrective actions.

MLTC Inspection Compliance/Responses:

• Ensures compliance activities and education are completed in response to inspection reports/findings.
• Ensures an action plan and associated documentation is completed and records for follow-up and presentation to MLTC.
• Ensures departmental responsibilities for compliance related activities are completed and facilitated by the department head. 

Interdepartmental Audits:

• Responsible for the completion of both scheduled and randomized audits for all departments, using the Inspection Guidelines to identify gaps in process or procedure and works with the department lead to correct any identified gaps.

New Programs/Initiatives:

• Responsible for the planning, implementation, evaluation, and support of new programs/initiatives that the Senior Leadership Team determines is of benefit to the home.
• Working with the interdepartmental team to plan and roll-out new processes/programs/initiatives, and prepared evaluations and reports as required.