Director, Quality Improvement

POSITION SUMMARY: Assumes responsibility and accountability for the organization-wide Continuous Quality and Performance Improvement program and reporting both process and metrics to meet regulatory, safety and accreditation standards. The Director of Quality will assist the Vice President, Chief Operating Officer, Leadership and Medical Staff to establish priorities for Performance Improvement. The Director of Quality will focus on measuring, analyzing and trending information in order to improve outcomes. They will assure ongoing monitoring of performance to ensure improvements are sustained. The role requires that the individual interfaces with a diverse range of clinical and administrative professionals, resolves complex policy and service issues and directs oversight of reporting activities. This position is responsible for identifying and recommending initiatives as a result of evaluation of community and member population needs. The Director of Quality will direct and assist in processes to identify inefficiencies and monitor the effectiveness of quality systems and make value-added recommendations to improve the quality of service.

Education: Bachelor's degree in an area of Healthcare, Informatics or Public Health. Master's degree preferred.

Certification/Licensure: CPHQ, CPHRM, Lean Project Management, RN preferred. CPR Required

Experience:

• 5-10 years of experience in Quality Improvement
• 5+ years of management experience
• 3+ years of experience in a healthcare setting

• 3+ years of experience in meeting regulatory and accreditation requirements
• Prior experience in developing policy and protocols.
• Experience in application of process improvement methodologies.

Skills and Abilities which may be representative but not all inclusive of those commonly, associated with this position:

1. Time/project management skills.
2. Solid background in facilitation skills, process analysis tools and qualities theories.
3. Possess initiative, flexibility, and self-motivation.
4. Excellent oral, interpersonal, and written skills, including preparation of meaningful narrative reports.
5. Ability to collect, analyze, apply, interpret, graph, display, and communicate data, policies, procedures and regulations effectively to all staff.
6. Understanding of Population Health, Social Determinants of Health and Health Equity.
7. Excellent knowledge of accrediting standards related to Ambulatory Care
8. Considerable discretionary decision making
9. Capable of being a team member as well as a team leader.
10. High degree of personal accountability and integrity demonstrated.
11. Excellent problem-solving skills and analytical ability
12. Strong research skills including data gathering and analyzing.
13. Good computer skills including the use of MS Office, SQL, VISIO, and e-mail software.
14. Working knowledge and experience in the application of process improvement tools.
15. Working knowledge of NextGen, practice management system, and EDR.
16. Able to facilitate meetings with Quality Teams and Quality Council
17. Able to follow guidelines related to both Compliance and HIPAA

Transportation Requirement: Must possess a valid driver's license and automobile with insurance coverage as required by the State of Missouri.

FUNCTIONS OF THE JOB

Essential Functions

1. Budgetary responsibilities for the Quality Department
2. Analyze and make recommendations for operational activities that will improve care and quality indicators that result in improved performance.
3. Facilitate regularly scheduled team evaluations that are directed at improving quality metrics, providing constructive feedback.
4. Perform care process, workflow, and outcome audits as necessary to meet The Joint Commission, HRSA, NCQA and other regulatory body requirements.
5. Collaborates with departments to develop performance targets and evaluate their outcomes.
6. Ensures that department priorities are aligned with Senior Leadership, the Quality Plan, Strategic Initiatives and the Community Needs Assessment.
7. Identify process inefficiencies and recommend appropriate solutions.
8. Lead key efforts to prepare for regulatory audits, which may include departmental education, trainings/ meetings and quality communication.
9. Guide teams in creating, designing, and formatting improvements needed to describe system changes.
10. Compile monthly/required statistical and narrative reports.
11. Educate workforce on the use of process improvement tools.
12. Serve as organization liaison to the accrediting organization(s) for scheduling accreditation survey activities.
13. Make presentations and represent Affinia Healthcare as requested.
14. Present regular reports to the Clinical Council and Board of Directors through the comparison of results to benchmark available data, the development of improvement activities and the implementation of actions to improve. This may be completed using lean tools such as control charts, scorecards, PDSAs, DMAIC, RCA, FEMA and Pareto charts.
15. Perform other duties as assigned.

Supervises: Quality Improvement Support Staff

NOTE: Affinia Healthcare is a Covid-19 Vaccine Mandated Employer. All employees of Affinia Healthcare are required to be vaccinated for Covid-19.

NOTE: SMOKING IS PROHIBITED IN THE WORK ENVIRONMENT

NOTE: ALL APPLICANTS MUST PROVIDE CONTACT INFORMATION FOR THREE REFERENCES