Title:                                 Director of Quality and Clinical Services

FLSA Category:               Exempt

Reports To:                      Chief Medical Officer

Date Issued:                     January 2025

Job Summary:

The Director of Quality and Clinical Services (DQCS) is responsible for providing leadership and oversight of Greater Baden’s quality activities, nursing and medical assistant staff competency and education, nursing management and programs. The DQCS plays an integral role in working collaboratively with the leadership team in maintaining The Joint Commission (TJC) accreditation, Patient Centered Medical Home (PCMH) recognition, and Health Resources and Services Administration (HRSA) recognition.  

Essential Functions:

• Implements and oversees Quality Assurance/Performance Improvement (QAPI) program. Ensures that the Quality Plan is implemented and updated as required.
• Provides leadership to the organization for its performance improvement activities, including setting goals and objectives for performance improvement.
• Works collaboratively with the Population Health team and Managed Care Organizations (MCOs) to ensure optimal patient care.
• Co-chairs the QAPI meeting and records meeting minutes. Reviews meeting minutes prior to the next meeting to follow up on anticipated deliverables. 
• Works with the co-lead clinicians on improving quality measures.
• Works with the leadership team to ensure the organization follows TJC, PCMH, and HRSA standards and initiatives and develops tasks forces to support the initiation and maintenance of all required standards.
• Works with department leads to facilitate value-based care transformation and promote health equity in the patient population.
• Monitors nurse-sensitive quality indicators and provides recommendations to improve nursing practice.
• Provides oversight of nursing practice and provides recommendations to improve nurse utilization in the organization.
• Oversees nursing needs for grants and ensures needs of the grants are being fulfilled.
• Provides oversight of clinical ancillary staff (Registered Nurses and Clinical Medical Assistants) competency and training and ensures mandatory trainings are initiated and completed on time.
• Provides oversight of the necessary education for Vaccines For Children (VFC) program and ensures pediatric sites are compliant with VFC standards.
• Creates systems, policies, and processes related to clinical practice to ensure the delivery of safe, quality care.
• Attends and actively participates in organizational committees, task forces, and professional organizations.
• Completes other duties as assigned.

Nonessential Functions:

• Attends and actively participates in leadership meetings, organizational committees, task forces, and professional organizations
• Provides clinical leadership and acts as a resource to other members of the health care team, patients, or other members of the community.
• Participates in local, state and national forums as appropriate for agency needs.   Develops and maintains relationships with community resources as appropriate for the needs of patients and the agency.

Core Values:

Quality, Respect, Equity, Integrity, Teamwork, Professionalism, Commitment

Direct Reports

• Ambulatory Care Nurse Manager

Indirect Reports

• Registered Nurses
• Training and Clinical Support Coordinator

Minimum Qualifications

• Current State of Maryland Registered Nursing License, Advance Practice Registered Nurse (APRN) License, or License to Practice Medicine required
• Master’s Degree in Nursing or in a relevant field required
• Current D.E.A. and C.D.S. License
• Board certification or eligibility in a primary care specialty. Board certification preferred, certification expected within one year of employment.
• Five (5) or more years of experience healthcare
• Knowledge and experience with Joint Commission requirements, essential
• Experience with data management, essential
• Patient Centered Medical Home recognition/accreditation experience, essential
• Knowledge of Federally Qualified Health center requirements, desired
• Insurability (malpractice)
• Current Cardiopulmonary Resuscitation Certificate (CPR)

Substitutions-None

Benefits 

As a full-time employee at Greater Baden, you will be eligible for a wide range of benefits, including those listed below:

• Health, dental, and vision insurance (Note: Premiums are paid throughout the year on a shared basis – partially paid by you and the balance paid by Greater Baden.);
• Life and Accidental Death and Dismemberment insurance paid on your behalf and the ability to pursue optional life insurance;
• Short Term Disability- Paid on your behalf by Greater Baden;
• Long-term disability insurance that you can elect on a voluntary basis;
• Paid-time off (PTO) to accrue up to 10 days, plus 1 additional day per year;
• 401k participation. Up to 4% employer match after one year of service if enrolled in company plan.

Core Competencies Needed

Problem Solving – Identifies and resolves problems in a timely manner; gathers and analyzes information skillfully, develops alternative solutions; works well in group problem solving situations; uses reason even when dealing with                                 emotional topics.

Communication Skills - Listen verbally in order to solve problems and provide information and direction, ensuring the experience is a positive one. Record issues and resolutions to maintain accurate records and data for further                                              analysis by management. 

Analytical Skills - The ability to tackle a problem by using a logical, systematic, sequential approach. Possess creative thinking, learning, systems thinking and problem solving. Must be effective at defining and solving problems in                                 order to ensure that the real, underlying challenge is understood and that solutions actually address it.

Healthcare Systems - Knowledge of healthcare and medical terminology.

Organizational Skills - Effectively managing tasks and information and organize information to ensure a timely response to questions. Develops and uses systems to organize and keep track of information or work progress. 

Results Orientation – The ability to focus on the desired results, setting challenging goals, focusing effort on the goals, and meeting or exceeding them.

Time Management - Understands what is required and prioritizes to get tasks/projects completed and establishes/implements an effective course of action (ex. establishes appropriate deadlines). Reprioritizes work efforts based on                                    changing situations and emerging issues (e.g., in response to organizational, systems, and/or schedule changes).

Collaboration - Engages others by gathering multiple views and being open to diverse perspectives, focusing on a shared purpose that puts the organization overall success first.

Risk Management/Compliance - Confidentiality principles and laws, maintain compliance with government contractual mandates.

Work Environment

This job operates in an outpatient office environment. This role is frequently exposed to fumes or airborne particles, and high stress situations or events.

Physical and Mental Demands

• Ability to cope with stress.
• The person in this position needs to occasionally move about inside the office
• Constantly operates a computer and other office productivity machinery, such as a calculator, copy machine and computer printer.
• The person in this position frequently communicates with patients and/or employees. Must be able to summarize and exchange accurate information.
• Must be able to lift or catch patient weighing more than 50 pounds in the event of emergency.
• Performs with frequent interruption or distractions.
• Adjust priorities quickly as circumstances dictate.
• Ability to interact appropriately with colleagues for different purposes in different context.
• Ability to perceive the nature of sound.
•  Expressing or exchanging information by means of the spoken word, or to convey detailed spoken instructions accurately, loudly or quickly.
• Ability to judge distances and spatial relationships to perceive objects where and as they actually are.
• Cognitive ability to analyze, count, summarize and synthesize information from multiple sources.
• Ability to recognize social or professional behavioral cues.

Compliance

This position requires compliance with Greater Baden Medical Services ( Health Center’s) compliance standards, including its Standards of Conduct, Compliance Program, and policies and procedures.  Such compliance will be an element considered as part of the Director of Quality and Clinical Services regular performance evaluation.

Language Skills

Ability to read and interpret written or verbal documents and instructions. Ability to speak effectively to patients, employees and/or stakeholders of the organization.

Travel

Must be able to drive between Greater Baden Medical Services, Inc. locations.