Director of Quality

Description

Job Summary: The purpose of this position is to implement the Quality Improvement Program and related activities. Quality Improvement is a systematic, formal approach to the analysis of practice performance and includes efforts to improve performance. Embedded in Quality Improvement is the monitoring and improvement of patient safety and patient satisfaction. Additionally, the incumbent will direct the Risk Management program for the organization--proactively identifying issues that may affect the ability of the clinic to provide highly reliable care. Quality Assurance is the systematic monitoring and evaluation of the various aspects of provided services to ensure standards are being met. Embedded in Quality Assurance is Compliance, Accreditation and Provider Credentialing to provide regular internal/external audits to ensure compliance with applicable regulations and accreditation requirements. The incumbent functions as an independent and objective body, reporting to the CEO, which reviews and evaluates compliance issues/concerns within the organization. The position ensures that all associates under the CEO are in compliance with rules, regulations, policy and guidelines as prescribed and approved by senior leadership, the Board of Directors and applicable agencies (e.g. HRSA).

Essential Functions:

Quality Improvement:

• Leads and actively participates in the planning, implementation, monitoring and analysis of clinic’s performance against the annual QI plan.

• Reports to CMO, CDO, CFO and CEO on quality issues, trends and action plans.

• Reports to the board of directors on quality and safety issues as needed.

• Chairs the Quality and Safety Sub-Committee, and reports all required information monthly.

• Conducts the quarterly review and reports through the Quality, Safety Sub-Committee to the Board of Directors.

• Develops and implements evaluation tools that will produce qualitative and quantitative data and findings to improve quality, efficiency, patient satisfaction and cost effective services.

•Monitors and manages the production of UDS reports in compliance with HRSA requirements.

• Directs quality improvement efforts to ensure that performance of clinical services meets or exceeds national benchmarks.

• Collaborates with Medical, Dental, Behavioral, Operations, IT and Finance leadership to champion coordinated population management for Marillac patients.

• Leads organizational efforts to retain NCQA PCMH recognition.

• Establishes and implements metrics (process capability, control charts, measurement quality) for monitoring system/process effectiveness and to enable managers to make sound quality decisions

• Converts data into useful information. Interprets and analyzes data for statistical significance and coaches Medical, Dental, Behavioral, Operations, IT and Finance services to improve outcomes.

• Acts as a resource in teaching and applying tools for performance improvement and data collection and analysis to all Marillac departments, as per the Annual QI Plan.

• Educates and trains employees to implement quality improvement (QI) activities as appropriate (e.g., PDSA, Six Sigma) to raise the performance of the health center’s product lines.

• Co-Chairs Quality and Safety Board Subcommittee meetings.

• Collaborates in the development of short and long-range goals for quality and safety performance for incorporation into strategic planning.

• Works closely with the Development Department to provide relevant data, goals and benchmarks for grant submissions and reporting, in a timely fashion.

Quality Assurance:

• Continually researches best performance and quality improvement practices. This includes relevant benchmarks for all aspects of dental, mental health, medical services and enabling services.

• Develops, collects and analyses patient satisfaction survey data for trends and recommends process improvement.

• Collaborates with operational leadership regarding patient grievances, reports grievances and action plans to subcommittee facilitates process change to address recommend improvements.

Patient Safety:

• Plans and implements patient safety policies and activities developed by the health center in support of National Patient Safety Goals.

• Exercises oversight and collaboration with key staff to ensure the effective integration of the Patient Safety Program functions by the organization.

• Collaborates with senior leadership and managers throughout the organization to ensure the health center participates in a “Just Culture” of safety. Develops staff surveys to assess culture and willingness to report unsafe practices.

• Lead response to incident reports to addresses patient safety issues and leads event analysis and development of corrective action plans.

• Collects, analyzes and reports patient safety data on selected patient safety measures to the Quality and Safety Board Subcommittee.

Patient Satisfaction:

• Initiates, monitors and reports findings from patient satisfaction surveys.

• Collects and evaluates patient grievances, identifying and reporting patterns.

• Collaborate with responsible leadership in responding to all grievances.

Risk Management:

• Monitors the health center’s Risk Management (RM) plan in order to mitigate risks— particularly Potentially Compensable Events (PCEs).

• Gathers facts regarding PCE’s with named providers, officers or staff in order to prepare the health center for case presentation. Interfaces with attorneys regarding PCE’s as necessary.

• Manages and implements programs, policies, and practices to ensure that all departments are in compliance with applicable law, regulations and accrediting bodies (The Joint Commission, HIPAA, etc.) • Works collaboratively with senior leaders and CEO to ensure compliance with federal, state, and local regulatory requirements.

• Audits the health center against known laws and regulations as well as patient grievance process for potential PCEs. Works with leadership and BOD to cover any gaps in the RM program through the deeming process or gap liability coverage.

• Ensures every provider is protected from liability while an employee at the health center by working with provider insurance companies and/or the FTCA deeming process.

• Identifies areas of potential vulnerability and risk; develops/implements corrective action plans in collaboration with leadership for resolution of problem areas and provides general guidance on how to avoid similar situations in the future.

Compliance:

• Develops, plans and implements policies and procedures to support clinical services. Manages and monitors the distribution, compliance and regular review of policies.

• Reviews policies and procedures of the clinic to determine deficiencies and ensure compliance with federal, state, and county agencies as well as active grants and regulations from accrediting agencies.

• Documents laws and regulations that might affect the organization's policies and procedures.

• Collaborates with other departments to direct compliance issues to appropriate personnel for investigation and resolution. Consults with attorney as needed to resolve difficult legal compliance issues.

• Responds and leads investigations into violations of rules, regulations, policies, procedures or standards of conduct by evaluating or recommending the initiation of investigation (e.g. RCA). Reports all such issues to appropriate senior leadership and CEO.

• Acts as independent review and evaluation body to ensure compliance with applicable regulations and reports regularly to CEO.

Accreditation:

• Participates in internal (e.g., Infection Control, Environment of Care) and external audits (e.g., RMHP, HRSA, CDPHE).

• Leads compliance audits against laws, policies and regulations and develops action plans with health center’s subject matter experts and leadership. Re-evaluates compliance throughout the year.

• Prepares the health center for state and federal audits from planning phase thru exit conference, preparation of action plans and rebuttals.

Provider Credentialing:

• Oversees provider credentialing and privileging activities for LIP’s on staff for Marillac Clinic.

• Ensures credentialing processes are in compliance with professional standards, bylaws, state and federal regulatory requirements.

• Supervises the Credentialing Verification Organization’s implementation of credentials process in support of the health center.

• Assists leadership and HR with managing

Other Duties and Responsibilities:

• As a leader of the organization, be alert to and insure that the best interests of the organization are maintained.

• Perform other duties and responsibilities as required.

Competencies:

• Knowledge of the principles and practices of quality improvement in an organization as well as clinical setting. Ability to evaluate and make recommendations for continuous quality improvement.

• Knowledge of primary care operations and Patient-centered Medical Home.

• Knowledge of risk management concepts and practices.

• Knowledge of applicable laws and regulations within the health care industry.

• Knowledge of applicable computer systems, programs and applications.

• Ability to research, analyze, interpret complex data and present comprehensive reports.

• Skill in exercising a high degree of initiative, judgment and discretion.

• Ability to communicate clearly and effectively orally and in writing.

Qualifications

Required Education/Experience:

• Bachelor’s degree or equivalent in a health related industry.

• Minimum of two to three years of relevant experience.

Preferred Education/ Experience:

• RN or Master’s Degree preferred

• Certified Professional in Healthcare Quality (CPHQ) or equivalent.

• Certified Professional in Healthcare Risk management (CPHRM) or equivalent.

• Experience in leading QI efforts as part of an application to NCQA for Patient-Centered Medical Home recognition

Additional Eligibility: Must be current or willing to be vaccinated for the following

o TDAP (up to date booster)

o MMR series

o Varicella

o HEP B series

o Flu Shot

o TB Screening

o COVID

Salary : $37 - $57