Director of Quality Improvement and Risk Management - Gateway Community Health Center

DESCRIPTION: Quality and Risk Manager is responsible for assisting in the overall direction, coordination and implementation of the CPIRM Program for the organization including Joint Commission accreditation standards and HRSA requirements. This will include the collection, management and analysis of quality data and the preparation of quality reports. Practical knowledge of tools and techniques of continuous quality and performance improvement, including analysis and interpretation of data using computer-based data (Intergy/Dentrix) or similar data collection systems is essential. Must be familiar with PCMH accreditation. The main goal of this position is to ensure the activities in the organization are meeting the quality standards to provide better care for patients and in ensuring compliance with all applicable laws/regulations/policy.

This position exists as a channel of communication to receive and direct compliance issues to appropriate resources for investigation and resolution, and as a final internal resource with which concerned parties may communicate after other formal channels and resources have been exhausted.

SUPERVISION: Directly supervised by Chief Operating Officer.

SUPERVISES: Compliance Assistant and CPIRM Manager.

TYPICAL PHYSICAL DEMANDS: Typically requires stooping, bending, reaching, kneeling and ability to move 25 pounds. Requires the use of office equipment including the printer, copier, fax, computer, calculator and telephone.

FUNCTIONS AND RESPONSIBILITIES:

• Responsible for assisting in the development and implementation of the CPIRM Program and assists COO/CMO in developing guidelines and systems for the center CPRIM Program.
• Responds to alleged violations of rules, regulations, policies, procedures, and Standards of Conduct by evaluating or recommending the initiation of investigative procedures.
• Develops and oversees a system for uniform handling of such violations.
• Identifies potential areas of compliance vulnerability and risk; develops/implements corrective action plans for resolution of problematic issues and provides general guidance on avoidance or resolve similar future situations.
• Conduct immediate/appropriate response to any serious occurrence/complaint representing actual or potential patient, visitor, or employee injury. Monitor and take subsequent actions to ensure learning, compliance, and documentation.
• Proactively evaluate areas of organizational risk based on internal assessment and external benchmarking and implement strategies and policies that promote patient and staff safety.
• Promote the occurrence reporting process including trending and reporting of results, identification of problem-prone areas, and facilitation of prevention initiatives.
• Analyze all statistical reports and advisories that identify risk management and patient safety patterns and trends for leadership.
• Monitors performance of CPIRM Program; relates activities on continuing basis, taking appropriate steps to improve effectiveness.
• Assists COO in preparation of CPIRM compliance reports to Board of Directors (BOD) on quarterly basis and update CEO & CMO of performance improvement and compliance status of the organization in accordance with established protocols.
• Stay knowledgeable about HRSA quality regulations, laws, business trends, measurement tools through continuing education, meetings, trainings, or other program related activities regarding quality improvement (TJC, HRSA, UDS, FTCA, AHRQ etc.)
• Provides general management support for HRSA/TJC site visit.
• Coordinates Joint Commission meetings/activities and works department directors in the collection of data as required.
• Assists COO in preparing of the annual FTCA deeming application to HRSA. Review and improve risk management and credentialing policies in accordance with FTCA requirement.
• Lead the review of serious occurrences requiring root-cause analysis or failure mode and effects analysis. Disseminate lessons learned and process improvement plans.
• Assists with the development and implementation of performance improvement projects.
• Acts as the Center's Risk Manager.
• Type letters, memos, forms, audit sheets/templates, reports, agendas and minutes as requested.
• Responsible for coordination and scheduling of meetings/conferences for CPIRM operations, including, but not limited to compliance & safety meetings/committees and sub-committees.
• Assembles and types reports; including, but not limited to, tracking, trending and reporting on incident reports using organizationally-approved grading schematic.
• Compiles and communicates departmental performance improvement reports submitted by CPIRM committee and subcommittee members/participants.
• Assists in the reproduction of education materials for CPIRM committee and subcommittee members/participants.
• Develops, maintains, and updates the incident reporting system and CPIRM related reports.
• Performs other related duties as assigned.

MINIMUM QUALIFICATIONS:

• Bachelors of Science degree in Nursing from an accredited college or university.
• Active license to practice as a registered nurse in Texas.
• Three years of full-time paid experience in public health nursing and at least one of which have included supervisory experience.
• Experience in healthcare organizational compliance, quality and risk.
• Proven management ability and experience including a thorough understanding of quality improvement processes, tools, and techniques; quality measurement and reporting; root cause analysis and preventive risk management strategies; accrediting bodies' standards; and state and federal regulations.
• Ability to function effectively, independently, and efficiently in a demanding and dynamic work environment.
• Computer skills with Microsoft Windows and Office Professional (Word, Excel, and PowerPoint), including knowledge of computer technology in a health care setting.
• Bilingual in English and Spanish preferred.
• Possess means of transportation.
• Valid Texas Driver's License and minimum liability insurance.

PREFERRED QUALIFICATIONS:

• Master's preparation (MHA/MHSA/MPH) and risk management certification highly desirable.
• Broad-based knowledge of the scope of operations of a community health center
• Demonstrated ability to develop studies and conduct reviews using measures or indicators

SKILLS AND ABILITIES:

• Must have excellent organizational and grammatical skills.
• Ability to communicate well orally and in writing.
• Ability to manage time effectively and efficiently.
• Strong interpersonal skills. Ability to work effectively and to deal tactfully with professional personnel as well as with the public.
• Excellent writing and presentation skills.
• Demonstrated ability to develop studies and conduct reviews using measures or indicators
• Able to organize work, develop procedures and follow instructions.
• Projects a positive and professional image of Gateway Community Health Center.
• Able to maintain confidential documents and information.
• Work flexible hours.