Director of Healthcare Quality

JOB TITLE:                           Director of Healthcare Quality

DEPARTMENT:                   Administrative/Clinical

SUPERVISED BY:               CEO and Chief Health Officer

SUMMARY:

The Director of Healthcare Quality works as a part of the clinical provider team performing a variety of administrative and direct patient services inclusive of ensuring each Redesign Team® is performing effectively and efficiently.  The Director of Healthcare Quality is also responsible for all Quality Matrix reporting functions, staffing the Quality Improvement committee, and chart audits that occur and are reported on a routine basis as established by SWLA.  The Director of Quality is also responsible to ensure that SWLA has the clinical component of EHR eClinical Works, and all clinical modules in place.  Ensures that Template changes and EHR Training on clinical modules is provided.  The Director of Healthcare Quality is an integral part of the management structure and the clinical provider team and will work in concert with the Chief Health Officer to ensure compliance with all Federal, State, and HRSA, JACHO and NCQA regulations and requirements.

EDUCATION, TRAINING AND EXPERIENCE:

1. Graduate of an accredited school of nursing recognized by the Louisiana State Board of Nursing.
2. Possess a current, unencumbered LA License to Practice Nursing.
3. Able to relate with effectiveness to patients and providers.
4. Currently card qualified in basic life support techniques.
5. Previous experience with Electronic Medical Records.
6. Knowledge of Health Center billing and EHR Centricity and eClinical Works.

JOB RESPONSIBILITIES:

1. Assists CHO in scheduling and executing the bimonthly Quality Improvement Committee meetings.
2. Assures that the minutes from QIC meetings are recorded and transcribed on a timely basis.
3. Assists in the review and revision of the annual Quality Improvement Plan.
4. Ensures that all Case Management Staff activities are maintained.
5. Assures that Health Center data is produced, collated and reviewed with respect to the benchmarks articulation by HRSA, NCQA and JACHO.
6. Assures timely reporting of data as required by HRSA, JACHO, NCQA and LPCA.
7. Acts as the liaison for SWLA to the Quality Forum.
8. Reviews patient records ensuring compliance with required standards and that all encounters are closed out daily.
9. Attends all medical staff meetings and participates in SWLA’s Quality Improvement program(s) and the Infections Control programs.
10. Reports data and studies trends to improve the overall care and patient outcome.
11. Attains goals or improvements established for the employee.
12. Ensures clinical personnel are optimizing the requirements of Redesign®.
13. Ensures all Clinical personnel understand the requirements to maintain optimal performance through the NCQA Medical Home Recognition Program.
14. Responsible for patient’s awareness of SWLA’s capability to send prescriptions via mail to their homes.
15. Educates patients and their families the responsibilities regarding Patient Centered Medical Home® Program.
16. Consults with CHO/Director of Health Services/Medical Director on a daily basis to ensure compliance with HRSA, JACHO and NCQA requirements.
17. Performs additional essential duties as required by SWLA to meet the goal of providing primary health care services.
18. Attends all meetings as requested by CHO/Health Services Director/Medical Director, COO or Health Services Director/Medical Director.
19. Assumes additional duties when necessary and works overtime as required.
20. Assists CHO/Director of Health Services/Medical Director in organizing programs, writing or reviewing policies and procedures, and improving clinical operations to assure that SWLA Clinical Operations are meeting the needs of the patient.
21. Address and support cultural practices as long as such practices do not harm others or interfere with the planned course of medical therapy.
22. Ensures that clear, concise and current written policies and procedures are available to assist the staff and minimize the risk factors.
23. Participates with management, medical staff and clinical leaders in the facility’s decision-making process.
24. Enforces that nursing leaders are reviewing monthly performance improvement compliance with established indicators and sees that corrective actions are taken when negative outcomes are identified.