Director of Quality

Sunset Health•Yuma, AZ

12d

About The Position

The Director of Quality develops, initiates, maintains, and revises policies and procedures for the general operation of the Continuous Quality Assurance and Performance Improvement (QAPI) Program, and Risk Management Program. This role manages the day-to-day operations of these programs, reviews and investigates incident reports to identify system improvement opportunities, and collaborates with other departments to promote process improvement and risk reduction strategies. The Director also provides administrative oversight of the chronic disease management program, coordinates care for patients with chronic conditions, and assists in the development of clinical outcome measures. This position chairs the Policy & Procedure (P&P) Committee, facilitates NCQA PCMH recognition and renewal, and actively participates in various committees related to quality and risk management. Additionally, the Director completes an annual evaluation of the QAPI plan, chairs the QAPI Work Group, and facilitates provider and system-wide improvement efforts. This role ensures the safety and security of the organization's assets and processes, mitigates enterprise risks, and analyzes agency compliance with regulations. The Director also coordinates regulatory survey activities, participates in audits, and works with clinical teams to enhance patient and employee satisfaction. A key responsibility is developing and maintaining the SH care management/coordination program to improve patient care outcomes within established guidelines. Performs other job-related functions as requested/required.

Requirements

Bachelor’s Degree in nursing or healthcare administration or related field.
Minimum two (2) years management experience.
Minimum five (5) experience in a healthcare organization.

Nice To Haves

Masters preferred.
Additional education in risk/quality management and The Joint Commission standards preferred.

Responsibilities

Develops, initiates, maintains, and revises policies and procedures for the general operation of the Continuous Quality Assurance and Performance Improvement (QAPI) Program, and Risk Management Program.
Manages day-to-day operations of these programs.
Reviews, assists in investigation, monitors, tracks, and trends incident reports to identify opportunities for system improvement and reports the information to leadership and/or the Board of Directors.
Collaborates with other departments to promote process improvement and risk reduction strategies in response to complaint/concern data.
Provides administrative oversight of the chronic disease management program, oversees patient education, facilitates appointment setting, and closes gaps in care.
Collaborates in care coordination of services to patients with chronic medical conditions.
Assists in the development of clinical outcome measures, related tracking and monitoring systems and a mechanism to integrate efforts into organization-wide quality initiatives, including value-based care.
Chairs the Policy & Procedure (P&P) Committee, ensuring organizational leaders are aware of HRSA, ADHS, NCQA, and FTCA P&P requirements.
Facilitates NCQA PCMH recognition and renewal efforts, including training and application tracking and submission.
Actively participates in a variety of committees providing information, reports, and recommendations relevant to quality, and risk management.
Completes an annual evaluation of the Continuous Quality Assurance and Performance Improvement Plan and recommends necessary updates and/or revisions.
Chairs the QAPI Work Group with primary responsibility for preparing agenda, overseeing PDSA initiatives, and facilitating process and/or quality improvement efforts.
Facilitates provider and system wide improvement efforts to meet organizational goals and performance requirements.
Reviews and analyzes quality improvement and risk minimization indicators; prepares follow-up documentation and implement changes as needed.
Helps ensure the safety and security of all the people, assets, and processes across the organization.
Mitigates enterprise risks that may threaten the existence of the company, its reputation and stability.
Analyzes agency compliance with regulations and other requirement from external organizations, such as the Arizona Department of Health Services (ADHS), OSHA, FTCA, and HRSA.
Coordinates regulatory survey activities including, but not limited to, HRSA, ADHS, The Joint Commission, CMS, and NCQA.
Participates in internal and external audit processes.
Works in partnership with the clinical teams to enhance overall satisfaction for patients, visitors, and employees, including a proactive approach to resolving problems and complaints with respect to care, treatment, rights, and ability to access healthcare services.
Develops and maintains SH care management/coordination program to improve overall patient care outcomes, within HRSA, ADHS, NCQA PCMH and CMS guidelines.
Performs other job-related functions and activities as requested/required.