Quality Improvement and Accreditation Director

COQUILLE INDIAN TRIBE•Coos Bay, OR

11d•$92,706 - $115,877•Onsite

About The Position

Under the direct supervision of the Chief Operating Officer, the Quality Improvement and Accreditation Director is responsible for leading, developing, and implementing comprehensive quality improvement, patient safety, and risk management programs. Provides strategic leadership for organizational performance improvement through the development of clinical benchmarking systems, enterprise-wide quality reporting, population health measurement, and cross-departmental improvement initiatives that support integrated, team-based care and advance the health and wellness of Tribal members and communities.

Requirements

Bachelor’s degree in nursing or other health related field required.
Certified Professional in Healthcare Quality (CPHQ) or eligibility to obtain within 6 months of employment required.
Minimum five (5) years of experience in a clinical healthcare setting required.
Minimum five (5) years of experience in health care quality improvement and risk management required.
Minimum five (5) years of supervisory experience required.
Extensive knowledge of Microsoft Office, desktop publishing techniques and web publication software products required.
Must have proven track record as a team player.
Must possess a current, valid driver’s license and maintain an insurable driving record as determined by the Tribe’s insurance carrier.
Candidate must pass a pre-employment drug screen and Criminal and Character Background Check.

Nice To Haves

Preference given for work experience in Tribal health care setting.
Technical report writing skills preferred.
Knowledge of Indian Health Service and Bureau of Indian Affairs programs preferred.

Responsibilities

Provide leadership and oversight for quality improvement, quality assurance, patient safety, and risk management initiatives that improve outcomes for staff, patients, clients, and the Health and Wellness Division.
Develop and oversee processes for monitoring and improving quality of care.
Supervise the Quality Improvement Manager and other assigned staff, providing direction, coaching, performance management, and professional development.
Design, implement, and evaluate a comprehensive clinical quality measurement and benchmarking program.
Collaborate with leadership and clinical teams to establish meaningful quality metrics, monitor performance against internal and external benchmarks, and identify opportunities for improvement.
Lead the collection, analysis, interpretation, and presentation of clinical and operational performance data to support strategic decision-making, operational efficiency, regulatory compliance, accreditation, and organizational accountability.
Develop and oversee quality dashboards and scorecards that communicate performance outcomes, benchmark comparisons, trends, and progress toward strategic and operational goals.
Lead organization-wide performance improvement initiatives using evidence-based methodologies, including PDSA and root cause analysis.
Develop corrective action plans and monitor the effectiveness and sustainability of interventions.
Partner with medical, dental, behavioral health, pharmacy, rehabilitation, nutrition, community/public health, and other leaders to develop quality improvement and community health initiatives that advance team-based, patient-centered, culturally responsive care and improve health outcomes.
Collaborate with executive leadership to establish annual quality priorities, organizational performance targets, and department-specific goals aligned with Health and Wellness Division strategic objectives and Tribal health priorities.
Monitor healthcare disparities, health equity measures, access, utilization, and population health outcomes.
Partner with leadership to develop strategies that improve outcomes while honoring Tribal values, traditions, and culturally informed practices.
Collaborate with information technology, electronic health record teams, and department leaders to improve data integrity, reporting capabilities, and use of clinical information systems to support quality improvement and population health management.
Promote a culture of continuous quality improvement by providing education, coaching, and technical assistance to leaders, providers, supervisors, and staff regarding quality improvement principles, performance measurement, patient safety, and regulatory requirements.
Oversee and support the incident review and complaint process for KWC and use findings and trend data to identify opportunities for ongoing quality improvement and risk reduction.
Oversee and support preparation for regulatory and accreditation reviews, including AAAHC, CARF, and other applicable oversight organizations.
Educate and assist department supervisors in maintaining policies and procedures that meet regulatory and organizational requirements.
Ensure policies and procedures are reviewed regularly and that operational practices are consistent with approved policies.
Lead Quality Improvement Committee meetings or support an assigned designee and ensure follow-through on committee recommendations and action items.
Coordinate complex, system-wide projects involving multiple departments, programs, and functional areas, ensuring effective communication, implementation, and follow-through.
Perform other duties as assigned.