Director of Quality Improvement

Anywhere

Position: Director of Quality Improvement

To: Chief Quality Officer/Risk Manager (CQO/RM)

FLSA Status: Exempt
Personnel Supervised: Quality Improvement Assistants_

POSITION SUMMARY:

The Director of Quality Improvement has the responsibility of overseeing, directing and coordinating the activities related to clinical and operational quality outcomes. The Director will utilize health information technology, reporting tools, and data systems to support the activities for continuous quality improvement and developing plans to meet quality outcome objectives. The Director will work collaboratively with other team members such as Health Center Administrators, Nurse Managers, and Directors, to assist in maintaining Joint Commission Accreditation and Primary Care Medical Home Certification standards. The Director will work with CFHC leaders report quality improvement initiatives to other departments, the CQO/RM and other leadership regarding the performance improvement projects and their outcomes. The Director will provide guidance and direction to the QI Assistants as they complete their day-to-day tasks and ensure that the department meets all deadlines and project goals. The Director will support company policies, goals, and objectives established and approved by the CEO and the Board by performing duties personally or through a team concept.

The duties outlined which include, but are not limited to, shall be performed in accordance with the corporation’s policies, procedures, Mission and Vision Statements, Overarching Goal, CFHC’s Performance Expectations, CFHC’s Quality Improvement Plan (QIP), HRSA’s Compliance Manual, Joint Commission’s Standards and all other Federal and State Guidelines.

This position coordinates, as necessary, with other staff members, Department Heads, supervisors, and all other appropriate agencies.

MINIMAL QUALIFICATIONS:

  • Bachelor’s Degree in Nursing or Associate’s Degree in Nursing with 4 years clinical experience or Bachelor’s Degree in Healthcare or Business Administration with equivalent years of experience in quality assurance/improvement/management
  • Minimum three years’ experience in healthcare with a demonstrated working knowledge of quality and data management
  • Leadership experience
  • Strong Communication Skills, both written and oral
  • Strong Computer Skills
  • Working Knowledge of Quality Measures
  • High personal integrity and the ability to keep sensitive information confidential

RESPONSIBILTIES AND PERFORMANCE EXPECTATIONS include, but are not limited to, the following:

  1. Obtain/maintain proficient knowledge of CFHC’s mission, vision, and Performance Expectations. Become well versed and comply with the company’s policies and procedures as well as state/federal guidelines and standards of other regulatory agencies
  2. Understand the requirements of the CFHC’s Quality Improvement Plan and implement the objectives and goals of the plan
  3. Utilizes the PDSA (Plan, Do, Study, Act) model for performance improvement projects. Teaches others and assists them to utilize the PDSA model for their projects as well.
  4. Supervise, lead and guide the Quality Improvement Assistants in their day-to-day activities, assign duties and follow up on progress
  5. Responsible for full understanding of the HRSA quality measures and collaborates with other teams to identify improvement activities to improve on measures
  6. Maintains full understanding and knowledge of both Joint Commission standards and HRSA Compliance Manual
  7. Will work cohesively with CQO/RM and others in preparation for Joint Commission survey, HRSA On Site Visit Survey, and any other surveys as identified
  8. Maintains up to date Joint Commission and HRSA Survey documentation through electronic software or other means
  9. Maintains a complete understanding of Primary Care Medical Home definitions and standards through Joint Commission and assists the various team members in ensuring they are maintaining these minimum standards Maintains a working knowledge of HRSA Quality Badges and each badge measures with the understanding of how identified improvement activities will help to maintain or secure additional badges
  10. Oversees and ensures Provider Peer Review and Scorecards for identification of areas of challenge and successes for ongoing provider performance as well as credentialing and privileging
  11. Works with team to conduct, analyze and trend clinical data through internal and external auditing systems such as the electronic health record and Florida CHARTS, etc.
  12. Monitors patient satisfaction reports and identifies areas of improvement working with site leadership for trends and plans of action
  13. Develops quality reports to provide to committees and leadership
  14. Chairs the QUIRCS Committee (Quality, Infection Control, Risk, Compliance, Safety)
  15. Demonstrates an organization wide understanding of policies and procedures; has overall responsibility for monitoring and maintaining company-wide policies and procedures
  16. Participates in new hire onboarding related to areas of responsibility
  17. Reviews and approves time sheets for direct reports
  18. Provides feedback on an ongoing basis as well as 90-day evaluations and annual evaluations for direct reports
  19. Works cohesively with the other QI/Compliance/Risk Team for identifying efficient processes and training tools to educate all pertinent staff
  20. Assist with Uniform Data System audits and data analysis
  21. Attends meetings in coordination with the Quality/Risk staff and other appropriate staff, as requested
  22. Assist with receiving and reviewing surveys that are quality or risk related or are brought to the quality team for a project. Coordinate the compilation of measurable data annually
  23. Able to work independently as this position may not be in the same physical office space as the other Quality/Risk Team members or the CQO/RM for daily routine responsibilities. In addition, this position may require travel to all centers to complete the site-specific audits.
  24. Assists the CQO/RM with other assignments, as needed
  25. Perform other duties as assigned or necessary

PHYSICAL REQUIREMENTS:

  1. Able to work flexible hours
  2. Standing/walking/sitting for long periods
  3. Independently mobile

American with Disabilities Act (ADA) Statement: External and internal applicants, as well as position incumbents who become disabled, must be able to perform the essential job specific functions (listed within each job responsibility) either unaided or with the assistance of a reasonable accommodation to be determined by the organization on a case-by-case basis.

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