Quality Manager

Job Description

POSITION PURPOSE

The Quality Manager is responsible for the broad development, implementation and administration of HH’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. CMS, AAAHC, etc.). Serving as the Chair of the Quality Management & Improvement (QMI) and Risk Management (RM) committees, the Quality Manager utilizes outside resources for complex questions regarding quality, accreditation and compliance while actively participating in all QA/QI collaborations within HH. In addition to leading and assisting with organizational efforts to collect, analyze, and act on system data and outcomes, the Quality Manager also functions to summarize and present quality improvement information for HH as well as train staff internally on quality program tools and goals utilized at HH.

ESSENTIAL DUTIES, FUNCTIONS & RESPONSIBILITIES

This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all inclusive.

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 HH’s Quality Management & Improvement (QMIC) and Risk Management (RMC) 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 HH’s Executive Leadership Team and Health Board; and acts as the primary Survey Liaison with AAAHC.

· 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.

· 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.

· Oversee the development, implementation, and maintenance of HH’s policies.

· Helps to coordinate and supervise organizational clinical audits.

· Oversee and manage the HH organizational projects that are presented to QMIC on an ongoing basis.

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

· 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 HH’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 communicates findings with medical staff and leadership as necessary, including the provision of information for and active involvement in HH’s clinical peer review process.

· Analyzes all assigned areas for opportunities of improvement 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.

· Addresses 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 HH.

· 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.

· Perform other duties as assigned.

MINIMUM MANDATORY QUALIFICATIONS:

Experience:

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

o Five (5+) or more years of managerial or leadership experience in healthcare setting. Demonstrated ability to hire, manage, develop and coach team members.

Education: Bachelor’s degree in nursing, Public Health, or a related healthcare degree from an accredited institution

· Must pass background screenings.

POSITION PREFERENCES

· 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 Healthcare Risk Manager (LHRM) designation(s) preferred.

· Bilingual skills in English and the Keres native language.

· Prior experience working in a tribal 638 organization.Company Description

Haak'u Health Center, formally Acoma/Canoncito/Laguna (ACL) Clinic is now hiring! Please consider joining the Haak'u Health Center team.

Full-time