Director of Clinical Quality

Copper Ridge Surgery Center is an award-winning, multi-specialty outpatient Ambulatory Surgery Center (ASC). We are the largest ASC in Michigan with 8 ORs and 4 Endoscopy procedure rooms.

The Director of Clinical Quality is a member of the Leadership Team and oversees the Center’s Clinical and Administrative Quality Assurance and Performance Improvement (QAPI) Programs, survey readiness and regulatory compliance. This role works collectively with the Medical Director and Director of Clinical Operations to ensure the delivery of high-quality patient care. This role also ensures the Center meets or exceeds state, federal and regulatory standards, while focusing on a positive patient experience.

Key Areas of Responsibility:

Quality Assurance and Performance Improvement

• Collaborates with administration to develop and maintain appropriate policies, protocols and procedures that ensure patients’ safety, comfort, and quality of care throughout patients’ experiences with the Center.
• Directs the Center’s Clinical and Administrative QAPI Programs. Plans agenda and leads QAPI meetings.
• Oversees occurrence reports that are a result of clinical quality processes. Plans, recommends, evaluates, and implements initiatives for improving Center’s clinical performance through QAPI studies and other process improvements.
• Oversight of data collection and reporting of internal and external benchmarking.
• Works with Medical Director and staff to establish appropriate patient clinical criteria, record-keeping, confidentiality of patient information including HIPAA guidelines, processing of scheduling, identification, patient care and QA.
• Collaborates with Facility Manager to oversee the Safety Program, ensuring safe practices are in place for patients, staff, physicians, and visitors.
• Provides annual summary of Program Objectives evaluation to MEC and BOM.
• Functions as an active participant in the MARCQI as the Quality Administrator or other role as determined by the center.

Staff Development

• Develops and manages the Clinical Administrative Assistant to plan and prepare elements of the QAPI Program.
• Collaborates with the Infection Preventionist to support the infection control program.
• Develops and manages the Clinical Nurse Educator to ensure clinical staff competency, required certifications, cross-training, and orientation plans are attained.
• Promotes staff growth through certification, conferences, and continuing education opportunities.

Quality Reporting

• Serves as Quality Net Administrator to oversee and submit data to the CMS ASC Quality Reporting Program.
• Submits ASCA clinical and financial quarterly data for the purpose of external benchmarking.

Patient Experience

• Manages and reports on the patient satisfaction program, including patient survey responses and external benchmarking. Identifies trends and implements processes for continuous improvement.
• Responds to patient complaints and requests for follow-up, including patient grievances.

Survey Readiness

• Responsible for overseeing survey readiness (CMS, State, and Accrediting Association through staff education and remaining aware of changing requirements).
• Leads the AAAHC Committee to prepare for reaccreditation surveys.
• Ensures all clinical processes meet or exceed regulatory and accreditation agencies guidelines.

Administration Support

• Assists preparation and administration of the clinical budget. Ensures services operate within approved budgets, evaluates and reports variances.
• Evaluates and proposes enhancement of clinical services within budget guidelines and adjusts as needed.
• Support HR in staff recruiting, hiring, training, and education.
• Participates with administrative team in 24 hour accountability for the Center.
• Attendance at various meetings, including but not limited to, QA; MEC; BOM; ASCP; staff meetings; and leadership roundtable.

Maintains required licensure and certifications

Other projects and duties as assigned

Knowledge, Skills and Abilities:

• Demonstrated surgical services and clinical management experience with knowledge of accepted SGNA, ASPAN, AORN, and Michigan Department of Community Health standards
• Strong critical thinking, decision making and organization skills
• Change oriented and creative
• Effective interpersonal skills including those required during stressful situations
• Ability to understand and assist development of financial, statistical and QA reports
• Ability to extract, analyze, and benchmark meaningful data
• Strong written and verbal skills

Education and Experience:

• Graduate of accredited school of Nursing with current MI licensure
• BLS, ACLS, and PALS certifications required
• BSN Required, Masters in Nursing with a focus on quality and/or education preferred
• 5 years in ASC or comparable setting
• Certification in a related healthcare specialty (e.g., CAPA, CNOR) or healthcare quality professional

Job Type: Full-time

Benefits:

• 401(k) matching
• Dental insurance
• Employee assistance program
• Employee discount
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Vision insurance

Medical Specialty:

• Surgery

Schedule:

• Monday to Friday

Ability to Relocate:

• Traverse City, MI 49684: Relocate before starting work (Required)

Work Location: In person