Manager of Quality, Compliance, and Strategic Initiatives

Description

Position Function :

The Manager of Quality, Compliance and Strategic Initiatives manages assigned quality systems, reporting processes, review activities, and improvement projects under the direction of the CQSO.

As a Single Source Continuum Contractor (SSCC), OCOK is responsible for the quality and effectiveness of services delivered to children, youth, young adults, and families through its programs and contracted provider network. The manager supports this responsibility by coordinating quality review processes, analyzing performance and risk information, tracking improvement activities, and maintaining systems that support accountability and accreditation.

The position provides support to Contracts, Provider Relations, and Child Safety & Legal Compliance and collaborates with program leadership to strengthen service delivery and organizational performance.

Working Conditions :

Work is performed primarily in an office environment. Periodic travel within OCOK’s service area and occasional work outside regular business hours may be required.

Exposure to Confidential Information :

The Manager of Quality, Compliance and Strategic Initiatives will have access to confidential records, including youth files, DFPS Residential Child Care Investigations (RCCI) and Health and Human Services Commission (HHSC) Child Care Regulation (CCR) investigations, foster care/adoption records, foster/adopt parent information and biological family history. Must maintain confidentiality and follow policies related to personnel records and client records.

Key Expectations/Responsibilities :

Departmental Support

· Provide quality improvement tools, analysis, and project support to Contracts, Provider Relations, and Child Safety & Legal Compliance.

· Collaborate with Contracts and Provider Relations to maintain provider scorecards appropriate to provider type and services delivered.

· Support Child Safety & Legal Compliance in analyzing aggregated incident, complaint, grievance, and investigation information.

· Help department leaders standardize workflows, clarify responsibilities, and assess process effectiveness.

Strategic Initiatives, Accreditation, and Policy Management

· Manage assigned strategic initiatives and cross-department projects under the direction of the CQSO.

· Maintain project plans identifying deliverables, owners, milestones, dependencies, and completion dates.

· Coordinate follow-up and prepare status updates highlighting accomplishments, barriers, delays, risks, and needed decisions.

· Coordinate assigned Council on Accreditation (COA) activities, including work plans, evidence collection, readiness tracking, and follow-up.

· Support department leaders in demonstrating implementation of approved policies, procedures, and applicable standards.

· Develop, review, and revise assigned policies, procedures, and supporting tools in collaboration with subject matter experts, ensuring clarity, consistency, and alignment with contractual, regulatory, and accreditation requirements.

· Coordinate established policy and procedure review and approval processes.

· Manage the designated document control system for approved policies, procedures, forms, and related documents, including version control, review dates, accessibility, and retention of superseded materials.

· Maintain organized records of quality reviews, committee activities, improvement plans, and evidence of results.

Performance and Quality Improvement

· Manage implementation and maintenance of OCOK’s Performance and Quality Improvement (PQI) plan, including performance measures, quality review processes, reporting schedules, and improvement activities.

· Collaborate with department leaders to establish quality indicators, benchmarks, targets, and methods for evaluating services and operational effectiveness.

· Co-facilitate root cause analysis and development of improvement plans with measurable objectives, responsible owners, and completion dates.

· Track improvement and corrective action plans through completion, verify supporting evidence, and evaluate whether changes produce sustained results.

· Coordinate annual evaluation of service delivery processes, including stakeholder surveys and identification of barriers to accessing or successfully completing services.

· Engage leadership and staff in quality improvement activities that promote consistent practices and informed decisions.

Compliance and Risk Management Support

· Coordinate assigned internal case record review and peer review activities, including review schedules, sampling methods, tools, reviewer preparation, and documentation.

· Evaluate documentation and practice against approved policies, procedures, applicable contract requirements, and accreditation standards.

· Prepare review summaries identifying strengths, deficiencies, recurring findings, and recommended improvements.

· Communicate findings to responsible leaders and incorporate results into the PQI process.

· Track findings from external audits, monitoring visits, and regulatory or accreditation reviews through resolution.

· Coordinate review activities with existing monitoring functions to avoid duplication.

Committee Meeting Coordination and Compliance Training

· Coordinate assigned committee meetings, including agendas, reports, minutes, decisions, and action items.

· Follow up with responsible owners and report unresolved barriers or overdue activities to the CQSO.

· Support communication of relevant findings and approved improvements to department leaders and staff.

· Assess PQI training and resource needs and provide coaching on data collection, report interpretation, case record reviews, and improvement practices.

· Collaborate with designated subject matter experts to provide training on incident reporting, client rights, grievances, confidentiality, and related quality requirements.

· Coordinate with Training and department leaders to monitor relevant required training completion and identify gaps.

Data Systems and Quality, Safety, and Risk Reporting

· Use Microsoft 365 systems, including SharePoint, Microsoft Lists, Forms, and Power Automate, to organize information, streamline workflows, and support timely notifications and reporting.

· Manage a coordinated framework for internal and external reporting, including report requirements, contributors, review processes, and deadlines.

· Compile, validate, and analyze information from program systems, case record reviews, provider monitoring, incidents, investigations, complaints and grievances, audits, and other relevant sources.

· Prepare monthly monitoring reports, quarterly analyses, and annual summaries.

· Develop dashboards, scorecards, charts, and concise narratives using advanced Excel, Microsoft Power BI, Canva, and comparable tools to communicate performance, trends, risks, and improvement results.

· Maintain distinct reporting for internal OCOK concerns and network provider concerns while identifying shared or system-level issues.

· Communicate findings and recommendations clearly and promptly elevate significant performance concerns, risk exposures, and overdue actions.

Training

· Attends relevant in-service training offered at ACH to expand knowledge of services and the application of clinical skills.

· Attends mandatory training such as, but not limited to, Emergency Behavior Intervention, CPR and First Aid, Psychotropic Medications and Trauma-Informed Care training.

· Attends continuing education necessary to expand knowledge and maintain certifications or licenses.

· Adheres to all policies and procedures of the agency and its accrediting and standard setting bodies, such as Council on Accreditation (COA) and state licensing.

· Uses outside professional collaboration and intra-agency teamwork appropriate to the agency.

· Accepts direction from supervisor and implements supervisor’s suggestions and instructions.

· Understands the job de