Director of QA/QI

Job Description:\n\nQuality Assurance/Quality Improvement (QA/QI) Director Department: Quality Reports to: Chief Operations Officer (COO) FLSA Status: Exempt Type of Position: Full-Time Revised Date: 03/11/2023 MISSION & VISION STATEMENT: The Kewa Pueblo Health Corporation (KPHC) is established for the purposes of carrying out the vision and mission of the Santo Domingo Health Center (SDHC). The MISSION of KPHC is: “ENSURING HEALTH & WELLNESS THROUGH EXCELLENCE IN HEALTHCARE WITH RESPECT FOR CULTURE” and the VISION OF KPHC is: “HEALTHY PEOPLE, HEALTHY COMMUNITY, and HEALTHY LIFESTYLE”. POSITION PURPOSE: Reporting to the COO and acting independently to promote quality assurance in health care delivery and clinical operations, meaningful quality improvement activities, and awareness of areas of potential risk and mitigation within the organization, the Quality Assurance/Quality Improvement Director (QA/QI Director) is responsible for the broad development, implementation and administration of KPHC’s quality improvement and risk management programs.

This position serves as a content expert on performance improvement projects and measures, risk assessment and grievance resolution, and clinical and patient safety in compliance with the standards, rules and regulations of regulatory agencies (e.g.

IHS, CMS, AAAHC, etc.). Serving as the Chair of the Quality Management & Improvement (QMI) and Risk Management (RM) committees, the QA/QI Director utilizes outside resources for complex questions regarding quality, accreditation and compliance while actively participating in all QA/QI collaborations within KPHC.

In addition to leading and assisting with organizational efforts to collect, analyze, and act on system data and outcomes, the QA/QI Director also functions to summarize and present quality improvement information for KPHC as well as train staff internally on quality program tools and goals utilized at KPHC.

The QA/QI Director is a member of KPHC’s Executive Leadership Team (ELT). PERFOMANCE EXPECTATIONS: In performance of their respective tasks and duties all employees of the Kewa Pueblo Health Center are expected to conform to the following: Uphold all principles of confidentiality and patient care to the fullest extent.

Adhere to all professional and ethical behavior standards of the healthcare industry.Interact in an honest, trustworthy and dependable manner with patients, employees and vendors.

Possess and maintain an environment of cultural awareness and sensitivity enabling the facility to fulfill its mission by meeting or exceeding its goals.

Take responsibility for all day-to-day operations of the facility and health services provided to the patients.Maintain a current insurable driver’s license.

Comply with all Kewa Pueblo Health Corporation and Santo Domingo Health Center policies and procedures, as well Consistently maintains professional and ethical standards adhering to all KPHC Policies, Compliance Standards and HIPAA.

ESSENTIAL DUTIES, FUNCTIONS & RESPONSIBILITIES: Supervisory Responsibilities: Directs and oversees the Quality Control Department consisting of a Quality Data Analyst and Support Staff.

Directs and oversees the Safety and Security Departments consisting of a Security Manager and (6) Security Officers.

Directs and oversees Clinical Informatics Department.

Directs and oversees Infection Prevention Department.

Conducts performance evaluations that are timely and constructive.

Handles discipline and termination of employees in accordance with company policy.

Keeps timekeeping on all direct reports.

Duties/Responsibilities: Develop, administer, and monitor the day-to-day implementation of organizational Quality Improvement (QI) and Risk Management (RM) programs, including the development, maintenance, revision and coordinated approval of policies and procedures for these functions and the corresponding quality tools used (e.g.

PDSA cycles, A3 documents, templates, reports, etc.)Serve as the Chair of KPHC’s Quality Management & Improvement (QMIC), Risk Management (RMC), Forms and AAAHC Committees.

Provides input into the establishment of annual organizational goals for each function based on program intent, operational and environmental analysis, and prior year performance and incidents; coordinates annual accreditation standards review(s) (e.g.

AAAHC, CMS, IHS, etc.) with KPHC’s Executive Leadership Team and Health Board; and act as the primary Survey Liaison with AAAHC.Provides oversight of electronic medical record (EMR) system management including configuration and optimization of the system.

Oversight of end user access and training for staff on EMR (NextGen) and other platforms used for incident reporting (CIP), learning management (Relias), data management (Smartsheets), document archiving and attestation (DocTract), and electronic document signatures and workflows (AdobeSign). Participates in and leads (as required) the education of medical staff, employees, leadership and the Health Board on risk management and quality performance indicators selected by the organization, focusing on the requirements and implications of these measures for safe clinical practice.

High level oversight and coordination of infection prevention and control program activities including environment of care rounds, risk assessments, surveillance, and program reviews.

Performs retrospective and concurrent review of specific focused studies (including procedures, diagnosis and other studies) requested by medical staff, departments, leadership and committees.

Flags and documents variances for selected indicators and variables for focused studies and assists with the implementation of quality indicators for medical staff (e.g.

chart and peer review, medication errors, critical quality incidents, etc.). Knowledge of and ability to work with HEDIS and GPRA measures to promote quality improvement.

Manage and support physician peer review processes by ensuring the collection and analysis of data for provider FPPE/OPPE, scorecards, quality metrics, etc.

Oversees the development, implementation, and maintenance of the KPHC’s policies utilizing an electronic document archiving platform.

Helps to coordinate and supervise organizational clinical audits.

Oversee and manager the KPHC organizational projects that are presented to QMIC on an ongoing basis.

Prepare and implement the Quality Improvement Plan and Performance Improvement Projects.

Leverages existing data sources to develop automated reporting for leadership to utilize as part of internal and external reporting of metrics.

Participates in data extraction and preparation for submission of required data analysis and conclusions to oversight and/or accrediting bodies, including to the CEO and Health Board for monthly, quarterly, and annual reporting.

Coordinates receipt of, evaluation of, response assignment for, and closure of patient grievances/complaints, incident reports, adverse event investigations, root cause analysis, and other risk management processes requiring monitoring and resolution as provided for in the KPHC’s policies and procedures.

Identifies and interprets objective and subjective data found in medical records through a process of systematic chart reviews for clinical quality, and communicate findings with medical staff and leadership as necessary, including the provision of information for the active involvement of KPHC’s clinical peer review process.

Analyzes all assigned areas for opportunities of improvements and makes applicable recommendations for process, system, procedure, and operational changes to improve healthcare value and quality.

Perform and monitor Root Cause Analyses (RCAs) in cases where sentinel events have been identified.

Serves as an active member of the Executive Leadership Team in addressing performance deficiencies identified on Rolling Action Item Lists (RAILs), reports from inside (e.g.

infection control and/or safety committees) and outside entities (including mock surveys), incident reports, and other points of information.

Abstracts and reports performance improvement information in appropriate format to detect patterns and/or problems in the delivery of care.

Monitors all new and existing QI initiatives, providing comprehensive analyses and improvement ideas and integrating those concepts in the short and long term plans of KPHC.Creates and conducts or delegates quality program orientations and provider network audits as required.

Maintains current knowledge of pertinent laws, standards, trends, tools, and techniques to maximize quality and risk management program effectiveness, including maintenance of applicable professional credentials through continuing education, as required.

High level oversight and coordination of safety and security program activities, including risk assessments and program reviews.

Performs all other duties as assigned.

MINIMUM MANDATORY QUALIFICATIONS: Education: Bachelor’s Degree in Nursing, Public Health, or a related healthcare degree from an accredited institution.

Experience: Two (2) years of healthcare experience in an ambulatory or hospital setting, with exposure to and involvement in provider performance improvement activities.

Five (5+) or more years of managerial or leadership experience in healthcare setting.

Demonstrated ability to hire, manage, develop and coach team members.

Mandatory Knowledge Skills, Abilities and Other Qualifications: Knowledge of principles and policies of quality improvement and risk management programs including program structure, monitoring, evaluation, and reporting tools and processes (e.g.

PDSA cycles, A3 summaries, statistical analysis and charting, trend analysis and control limits, etc.). Knowledge of the Federal Tort Claims Act (FTCA) and OMB rate regulations Thorough understanding, knowledge and application of research, analysis, and assessment of compliance with federal regulations related to Medicare, Medicaid, HIPAA, Affordable Care Act, and other government laws and programs related to the healthcare industry.

Knowledge and understanding of the principles, procedures and associated regulations and standards for the delivery of rural, community-oriented health care delivery systems.

Familiarity with Indian Self-Determination contracting and the IHS system.

Computer literate and knowledgeable of various computer technologies and software including Word, Excel, the IHS RPMS/EHR, Dentrix, Nextgen and other comparable systems.

Self-motivated, goal oriented and flexibility to adapt to frequently shifting priorities.

Requires a professional image/demeanor as well as an extremely responsible working attitude with oral and written communication skills being an absolute necessity.

Individual must exhibit the highest level of integrity and ethics.

Frequently required to provide immediate response/assistance to the organization and its employees.

Clinical skills that facilitate active review and discussion of clinical documentation requirements and the provision of quality patient care as reflected in patient charts with other healthcare professional.

Knowledge of the Privacy Act, confidentiality and applicable rules and guidelines.

Extensive knowledge of appropriate accrediting and certification requirements, such as JCAHO, AAAHC, Medicare/Medicaid, OSHA, etc.

with knowledge of Primary Care Medical Home model.

Familiarity with the mandatory reporting requirements under the Indian Child Protection Act, with regards to suspected incidence of child abuse or child neglect.

PREFERRED QUALIFICATIONS: Master’s Degree in Nursing, Public Health, or a related healthcare degree from an accredited institution.

Two (2) or more years of direct experience with accreditation and survey preparation activities including credentialing, peer review, risk management, root cause analysis and investigations, and grievance resolution.

Two (2) years of proven ability in the areas of leadership, healthcare regulations, QA/QI principles, education outcomes development.

Certified Professional in Healthcare Quality (CPHQ), Six Sigma Performance Improvement Certification, Lean Performance Improvement Certification, and/or Licensed Health Risk Manager (LHRM) designation(s) preferred.

Bilingual skills in English and the Keres native language.

Prior experience working with Indian Health Services (IHS), a Tribe or Tribal organization.

WORK ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the primary functions of this job.

Normal office conditions exist, and the noise level in the work environment can vary from low to moderate.

This position may be exposed to certain health risks that are inherent when working within a health center facility.

PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the primary functions of this job.

While performing the duties of this job, the employee may be required to frequently stand, walk, sit, bend, twist, talk and hear.

There may be prolonged periods of sitting, keyboarding, reading, as well as driving or riding in transport vehicles.

The employee must occasionally lift and/or move up to 50 pounds.

Specific vision abilities required by this job include reading, distance, computer, and color vision.

Talking and hearing are essential to communicate with patients, vendors and staff.

MENTAL DEMANDS: There are a number of deadlines associated with this position.

The employee must also multi-task and interact with a wider variety of people on various and, at times, complicated issues.

OTHER: All employees must uphold all principles of confidentiality and patient care to the fullest extent.

This position has access to sensitive information and a breach of these principles will be grounds for immediate termination.

Disclaimer: The information on this position description has been designed to indicate the general nature and level of work performance by employees in this position.

It is not designed to contain, or be interpreted as, a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this position.

Employees will be asked to perform other duties as needed.

Applicants will be considered on the basis of whether they meet the minimum mandatory qualifications identified on the position description for the position applied for, including requisite experience, relevant education and possession of required licenses and certifications.

Among applicants who meet all minimum mandatory qualification for a position, preference will, to the maximum extent feasible, be granted to qualified Native American applicants.

Full-time