Director of Quality Improvement
Responsible for overall direction, coordination and implementation of the Quality Improvement Program for Community Medicine Foundation. This includes strategic leadership to support the organization’s mission of delivering healthcare based on continuous quality improvement.
Duties and Responsibilities include the following. Other duties may be assigned.
- Collaborates with Executive Team to envision, develop, and implement the organization’s quality improvement plan.
- Coordinates the process of monitoring, measuring, and assessment of patient care and support systems to achieve quality, safe, cost effective healthcare services.
- Coordinates and oversees the organization Quality Improvement Plan development, review, review and implementation.
- Coordinates and integrates QI plans and processes for individual services.
- Oversees the direct operations of the QI Department and its staff.
- Organizes, coordinates and attends all organization quality meetings and participates in all pertinent committee meetings where monitoring QI functions and activities are performed.
- Serves as a resource for clinical staff and internal services on quality improvement activities, education, and use of quality principles and tools.
- Facilitates, develops, and implements special projects as assigned by the CMO and CEO.
- Oversees regulatory readiness, quality measurement, and pay-for-performance programs and initiatives, holding staff and departments accountable for achieving performance goals.
- Establishes quality measurement and improvement activities, quality and patient safety awareness, safety culture survey administration, and recognition programs.
- Develops and implements QI/QA calendar of activities to meet primary care goals.
- Coordinates and reports Clinical Staff Quality Assurance/Improvement activities.
- Coordinates and manages Core Measures reporting and other functions.
- Collects and reports HEDIS and Population Health data for facility functions.
- Participates and assists in preparation for all clinical audits and surveys.
- Facilitate Continuous Quality Improvement teams as requested. Facilitate planning sessions as requested.
- Collaborates with Compliance and Risk Management Specialist.
- Teaches quality concepts to clinicians and other staff during orientation and in various educational settings.
- Leads the root cause analyses and failure modes and effects analyses and debriefings.
- Coordinates closely with information technology department to achieve organizational goals.
- Collaborates closely with the CMOs to develop, monitor, and educate others on the use of patient data systems that drive improvement and reporting of patient outcomes through the use of evidence-based data and scorecards.
- Promotes a culture of safety, high-reliability, and patient and staff engagement, and performance excellence.
- Develops, evaluates, and maintains quality dashboards and performance metrics.
- Supports and mentors employees of the department and other staff with interest in quality.
- Maintains current competency and expertise in quality and patient safety.
Qualifications:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education/Experience:
Bachelor of Nursing (with current SC License) or Master in Public Health degree preferred or 2-5 years of progressive experience in leading a quality improvement program in a healthcare facility.
Certificates and Licenses:
CPR certification required for nurses
Certified Professional in Healthcare Quality (CPHQ) preferred.
Knowledge, Skills and Other Abilities:
Knowledge of CQI principles, practices, methods, and tools.
Knowledge of computer applications related to QI, including spreadsheets.
Knowledge of medical records and clinical care processes.
Knowledge of one or more of: clinical standards of care, preventive health standards, HEDIS, NCQA, governing and regulatory agency requirements, and the managed care industry
Skill in effective education and facilitation of CQI efforts in medical practice.
Skill in application of analytical methods and statistical software by developing appropriate reports.
Skill in conducting QI checks of medical records and other clinical documentation and performing patient satisfaction surveys.
Ability to educate staff in both verbal and written form about QI in formal and informal settings.
Ability to interact effectively with health care team members.
Ability to analyze QI data and identify trends and corrective actions.
Knowledge of PCMH accreditation
Strong data collection, analysis and presentation skills
Ability to address quality issues with tact and diplomacy