Job Title: Quality Improvement/Risk/Accreditation Director
Office: Corporate
Department: Quality
Reports To: Associate Chief of Clinical Operations
FLSA Status: Exempt
OVERVIEW:To lead all aspects of quality improvement, risk management and coordinating and facilitating all aspects of organization's accreditation to ensure AHC's performance aligns with national measures and standards.
Duties, functions and responsibilities:- Develop, implement and monitor a comprehensive organizational strategy to ensure continuous improvement;
- Subject matter expert and champion responsible for working with and supporting leadership to improve quality measures, benchmarking, best practices and patient satisfaction;
- Develop ongoing programs to educate staff regarding quality standards, risk management and organizational improvement initiatives;
- Lead and manage risk management initiatives by
- effectively monitoring and identifying risks
- implementing risk mitigation strategies
- developing strategies to ensure adherence to desired outcomes and standards;
- Ensure interdepartmental collaboration to control costs, mitigate risks, adhere to industry standards and best practices by managing and monitoring risk management functions;
- Monitor changes from accreditation governing bodies and updates policies and procedures as appropriate.
- Assist with new-hire orientation program and training of new staff in accord with grant and regulatory requirements;
- Lead and manage all Infection Control efforts at all AHC locations;
- Lead and manage Quality Improvement Staff
- Primary contact for site visitor activities including but not limited to:
- Appropriate projection of site visit days
- Performs review and acceptance of Plans of Correction (POC)
- Finalizes accreditation finding and request-for-organization POC in response to all deficiencies;
- Leads performance improvement activities
Knowledge, skills, and abilities:- Knowledge in principles related to Patient Centered Medical Home, Meaningful Use and Quality Improvement
- Broad knowledge of population health management and preventive health screening standards
- Advanced working knowledge of risk analysis best practices and procedures
- Advanced working knowledge of Microsoft Excel, Access and system tools utilized for risk analysis
- Advanced working knowledge of relevant legal and regulatory requirements
- Detailed working knowledge of accreditation standards as they relate to FQHC's
Minimum qualifications:Education:
- Master's Degree in Health Services, Public Administration, or related field
Credentials:
- Certification in one or more of the following strongly preferred:
- Certified Healthcare Quality Professional (CPHQ)
- Certified Black Belt (Lean, Six Sigma)
Work Experience
- Demonstrated experience efficiently managing a professional staff, setting and maintaining clear and consistent standards for staff performance
- Experience developing and managing strategic plans, implementing goals in an organized fashion
- Experience in assessments, accreditation reviews, or audits where performance standards are established and reviewed
