Director of Quality

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.  A primary focus is to ensure key quality metrics are being obtained to ensure compliance with value based contracts and other quality incentives.  Embedded in Quality Improvement is the monitoring and improvement of patient safety and satisfaction and the optimization of staff workflows in the use of the electronic medical record.  Quality Assurance is the systematic monitoring and evaluation of the various aspects of provided services to ensure standards are being met. This position must work in close coloration with the Director Risk and Safety to achieve several common and overlapping organizational goals. 

Essential Functions:  

Quality Improvement:  

• Develops the clinic’s annual QI plan in conjunction with the CMO, CDO and Board of Directors. 

• 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.  

• Provides the Board of Directors with an annual summary of quality performance. 

• Provides the Board of Directors with an annual summary of the proposed quality plan for the next calendar year.  

• Co-chairs the Quality and Safety Sub-Committee, and reports all required information periodically (quarterly at minimum) including risk assessments and contingency plans.  

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

• Provides input into the conceptual framework for quality measurement and improvement activities across clinic sites and departments. 

• 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 obtain and retain NCQA PCMH recognition.  

• Establishes and implements metrics (process capability, control charts, quality measurement) for monitoring system and 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.  

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

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

• Supports and optimizes clinical information system projects and capabilities to meet the organization's goals of quality patient care, interoperability, operational efficiency, and regulatory compliance. 

• Reviews existing systems and suggests improvements.  

• Participates in EMR workflow analysis, user interface design, testing, and training development with project teams to maximize quality, functionality, and ensure efficient data collection.  

• Establishes communication, change management, and training curricula for quality initiatives. 

• Develops, modifies/ updates plans and implements policies and procedures to support clinical services.  

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. 

• Monitors the clinical quality measure and health information technology regulatory landscape to ensure timely compliance.   

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

Patient Satisfaction:  

• In conjunction with the Risk Management Director, initiates, monitors, and reports findings from patient satisfaction surveys.  

• In conjunction with the Risk Management Director identifies and implements efforts to improve patient satisfaction scores.  

• Provides leadership and the Board of Directors with a periodic summary (quarterly at minimum) of patient satisfaction scores and summary of improvement efforts.  

Compliance:  

• Assures accurate and timely data collection and reporting on quality measures to all required entities.  

• Regularly reviews quality requirements related to payer contracts. 

• Manages and monitors the distribution, compliance, and regular review of policies as related to quality and FQHC standards. 

Accreditation:  

• Participates in internal and external audits (e.g., RMHP, HRSA, CDPHE). This includes preparation for and participation in any site visits necessary to obtain or maintain designations and certifications. 

• Prepares the health center for state, federal and private insurer audits from planning phase thru exit conference, preparation of action plans and rebuttals as such audits may pertain to the quality program.  

Other Duties and Responsibilities:  

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

• Performs other duties and responsibilities as required. 

Competencies:  

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

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

• Knowledge of applicable quality standards 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. 

• Skill in creating a cohesive team environment that encourages productivity and performance. 

Required Education/Experience:  

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

• Minimum of two years of relevant experience. 

Preferred Education/ Experience: 

• Master’s degree in a healthcare related field. 

• Three years of clinical experience in nursing or similar clinical experience. 

• Certified Professional in Healthcare Quality (CPHQ) 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.  

• Tdap (up to date booster) 

• Measles, Mumps and Rubella 

• Varicella (or proof of immunity) 

• Hepatitis B  

• Seasonal influenza vaccine 

• TB Screening also required.