Director of Quality Improvement - Mile Square Health Center

University of Illinois Chicago•Chicago, IL

4d•Onsite

About The Position

The Director of Quality Improvement provides strategic and operational leadership for the quality improvement and performance management program at Mile Square Health Center. Reporting to the Chief Medical and Quality Officer, the Director is responsible for advancing a culture of continuous quality improvement, evidence-based practice, patient safety, health equity, and accountability for clinical outcomes. The Director leads the development, implementation, monitoring, and evaluation of organization-wide quality improvement initiatives and serves as a key resource for clinical and operational leaders in the use of data to improve patient care and organizational performance. Major areas of responsibility include HRSA Uniform Data System (UDS) quality improvement and reporting, Patient-Centered Medical Home (PCMH) recognition and ongoing requirements, HEDIS and other payer or regulatory quality measures, care gap identification and closure, and other strategic quality initiatives. As a registered nurse by training, the Director brings clinical expertise and a patient-centered perspective to quality improvement while working across disciplines and departments to translate performance data into sustainable improvements in clinical practice and patient outcomes. The Director also provides leadership and oversight for Quality Navigators and other quality improvement staff, establishes performance expectations and workflows, and partners with providers, nurses, care teams, and administrative leaders to achieve measurable and sustainable improvements in quality.

Requirements

Current licensure as a Registered Professional Nurse (RN) in the State of Illinois with the Illinois Department of Financial and Professional Regulation, Division of Professional Regulation.
Three years of professional nursing experience; or two years of professional nursing experience and one year of related advanced education.
Demonstrated experience in healthcare quality improvement, clinical performance improvement, population health, or a related healthcare field.
Demonstrated ability to collect, analyze, interpret, and present healthcare quality and performance data.
Strong written and verbal communication skills, with the ability to effectively communicate with physicians, advanced practice providers, nurses, patients, administrators, and multidisciplinary teams.
Demonstrated analytical, organizational, project management, and problem-solving skills.
Proficiency with Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook.

Nice To Haves

Bachelor's degree in Nursing, Public Health, Health Care Administration, or a related field; Master's degree preferred.
Three or more years of progressive experience in healthcare quality improvement, preferably in an ambulatory care or federally qualified health center (FQHC) setting.
Experience with HRSA Uniform Data System (UDS) reporting, Patient-Centered Medical Home (PCMH) recognition, HEDIS, or other healthcare quality programs.
NCQA PCMH Certified Content Expert (CCE) certification preferred.
Experience with electronic health record (EHR) reporting, clinical registries, population health tools, and quality data management.
Experience with grant writing, implementation, and management.
Experience leading multidisciplinary teams and supervising or mentoring quality improvement staff.
Experience with quality improvement methodologies and performance improvement initiatives.
Knowledge of applicable healthcare regulatory, accreditation, and compliance standards.

Responsibilities

Provide leadership and oversight for Mile Square Health Center's quality improvement and performance management program.
Develop, implement, and evaluate evidence-based quality improvement initiatives designed to improve clinical outcomes, patient safety, access, patient experience, health equity, and population health.
Lead quality improvement activities related to HRSA UDS clinical quality measures, including monitoring performance, identifying gaps, developing interventions, and evaluating outcomes.
Provide organizational leadership for PCMH recognition, application, renewal, and continuous improvement activities.
Manage the implementation and maintenance of PCMH throughout the Mile Square Enterprise.
Leads and manages PMCH transformation and ongoing medical home patient-centered activities.
Defines practice organizational structure and staff responsibilities/skill to support key PCMH functions.
Supports and trains staff on their roles and responsibilities.
Oversee quality initiatives related to HEDIS measures and other payer, state, federal, regulatory, or organizational performance measures, as applicable.
Establish systems for monitoring key quality indicators and ensure timely identification of performance gaps and opportunities for improvement.
Develop and maintain quality dashboards, scorecards, reports, and other performance management tools.
Analyze quality data and trends to identify opportunities for improvement and inform clinical and operational decision-making.
Translate performance data into actionable quality improvement plans with clearly defined interventions, responsible parties, timelines, and measurable outcomes.
Apply established quality improvement methodologies, including process improvement, root cause analysis, Plan-Do-Study-Act (PDSA), and other appropriate approaches.
Monitor the effectiveness, sustainability, and impact of quality improvement interventions and modify strategies as needed.
Collaborate with clinical and operational leaders to integrate quality measures and care gap closure into routine workflows.
Promote accountability for quality performance while fostering a supportive, learning-oriented environment.
Serve as a strategic advisor to the Chief Medical and Quality Officer and other organizational leaders on quality improvement, performance management, patient safety, population health, and regulatory priorities.
Develop, in collaboration with organizational leadership, annual and long-term quality improvement priorities, goals, and performance targets.
Ensure quality improvement activities are aligned with Mile Square Health Center's mission, strategic priorities, and commitment to equitable, patient-centered care.
Lead multidisciplinary initiatives that require collaboration across clinical, operational, administrative, and support departments.
Build and maintain strong partnerships with physicians, advanced practice providers, nurses, behavioral health professionals, care management staff, quality navigators, analytics staff, and other members of the care team.
Establish clear systems for communicating quality priorities, performance results, improvement opportunities, and organizational expectations.
Lead or participate in quality, patient safety, population health, and performance improvement committees and workgroups.
Provide leadership for organizational readiness related to PCMH, HRSA, quality audits, regulatory reviews, and other quality-related assessments.
Identify emerging quality and regulatory priorities and assess their potential impact on Mile Square Health Center.
Promote a culture in which staff at all levels are engaged in identifying problems, testing solutions, and improving systems of care.
Evaluate quality program effectiveness and recommend changes in priorities, resources, staffing, technology, and workflows to support organizational goals.
Represent Mile Square Health Center in appropriate institutional, community, academic, and external quality improvement initiatives and collaboratives.
Apply professional nursing knowledge and clinical expertise to the development and evaluation of quality improvement initiatives.
Partner with medical, nursing, and other clinical leaders to improve the quality, safety, effectiveness, and equity of patient care.
Identify opportunities to improve clinical outcomes through evidence-based practice, preventive care, chronic disease management, care coordination, and population health strategies.
Collaborate with clinical teams to identify and address gaps in care and barriers to achieving evidence-based quality measures.
Support the integration of quality improvement initiatives into clinical workflows in ways that promote sustainable improvement and minimize unnecessary administrative burden.
Provide clinical expertise in interpreting quality measures and developing appropriate clinical interventions.
Promote adherence to evidence-based clinical guidelines and standards of care.
Collaborate with providers and care teams to understand and address variation in clinical performance.
Support initiatives related to patient safety, care coordination, clinical effectiveness, health equity, and reduction of disparities in health outcomes.
Serve as a clinical and quality resource to providers, nurses, and other members of the care team.
Maintain professional nursing knowledge and competencies appropriate to the role and applicable standards of practice.
Provide direct leadership and oversight of Quality Navigators and other quality improvement staff, as assigned.
Establish clear roles, responsibilities, performance expectations, and measurable objectives for quality improvement staff.
Develop and optimize workflows for identification, outreach, and closure of patient care gaps.
Monitor team productivity, performance, and effectiveness and implement changes as necessary.
Provide coaching, mentoring, feedback, and professional development to quality improvement staff.
Participate in recruitment, onboarding, performance evaluation, and retention of quality improvement personnel.
Ensure staff receive appropriate training related to quality measures, patient outreach, care gap closure, documentation, and quality improvement processes.
Foster a collaborative, accountable, and high-performing team environment.
Encourage professional growth and development and support staff in building expertise in quality improvement and population health.
Promote effective communication and collaboration between Quality Navigators, providers, nurses, and other members of the care team.
Develop and provide education and training for providers, nurses, Quality Navigators, and other staff regarding quality measures, performance improvement, care gap management, regulatory requirements, and evidence-based practice.
Serve as an organizational resource for UDS, PCMH, HEDIS, and other quality program requirements.
Promote the use of evidence-based practices and current clinical guidelines in quality improvement initiatives.
Collaborate with academic and research partners, as appropriate, to support quality improvement, population health, health services research, and scholarly activities.
Contribute to the identification, development, writing, submission, implementation, and management of grants that support quality improvement, patient outcomes, population health, health equity, and related organizational priorities.
Partner with organizational leadership and internal and external collaborators to develop grant proposals, including defining project goals, objectives, measurable outcomes, evaluation strategies, and implementation plans.
Provide leadership in the implementation and management of quality improvement activities supported by grant funding, including monitoring deliverables, timelines, performance measures, and reporting requirements.
Collaborate with finance, research administration, and other relevant departments to ensure grant-funded quality improvement activities are implemented in accordance with funding requirements and organizational policies.
Facilitate evaluation of quality improvement initiatives and grant-funded projects and disseminate findings to relevant stakeholders.
Encourage presentation and dissemination of successful quality improvement initiatives through institutional, professional, academic, and community forums.
Support research and scholarly activities consistent with Mile Square Health Center and institutional policies and requirements.
Remain current on emerging evidence, national quality trends, regulatory requirements, funding opportunities, and best practices in healthcare quality improvement.
Other duties as assigned.