Summary of Position:

This position is responsible for identifying, implementing, monitoring and evaluating the overall clinical quality and corporate compliance at Community Health Centers of Greater Dayton (CHCGD). Collects and analyzes data and assists with performance audits and clinical training to identify improvement opportunities. Recommends action plans to address quality concerns and oversees the progress. Employee works collaboratively with all disciplines to establish a quality and safety culture, emphasizing clinical risk, patient safety, visitor, third party, volunteer, and employee safety, as well as potential business, operational, and property risks. Manages and monitors the CHCGD’s compliance effort, reporting identified issues directly to the Executive Director.

General Duties and Responsibilities:Technical/Professional Knowledge and Skills: Possesses, acquires and maintains the technical/ professional expertise required to do the job effectively. Demonstrates knowledge through problem solving, applying professional judgment and competent performance.

Quality Orientation: Monitors and checks work to meet quality standards; demonstrates a high level of care and thoroughness; checks work to ensure completeness and accuracy.

Managing Change: Ability to demonstrate support for innovation and for organizational changes needed to improve the organization’s effectiveness; initiating, sponsoring and implementing organizational change; helping others to successfully manage change.

Communication and Teamwork: Participates as an active and contributing member of a team to achieve team goals. Works collaboratively with others, involves others, shares information as appropriate, shares credit for team accomplishments.

Adaptability and Innovation: Adapts well to changes in assignments and priorities, adapts behavior or work methods in response to new information, changing conditions or unexpected obstacles. Uses creativity and imagination to develop new insights into situations and applies new solutions to problems. Core Value of Creative Care: open to change, optimistic, focus on learning and sharing.

Developing Others: Ability to work with others and coach them to develop skills and abilities. Sets clear performance expectations and objectives and holds others accountable for achieving results. Finds resources, training and tools to support staff needs.

Specific job duties include, but are not limited to:
• Coordinate and/or perform periodic medical review audits to ensure continuity of care and to assess quality indicators.
• Establish and measure quality indicators periodically at a determined interval.
• Develop and utilize electronic method of data collection and storage.
• Produce/validate reports on identified quality indicators results.
• Target low-performing indicators with improvement strategies and track changes over time to ensure strategies have been effective.
• Prioritize targeted areas for improvement and develop planning timeline to address them.
• Lead QA small groups in utilizing the PDSA methodology for quality improvement efforts.
• Analyze data collected through patient satisfaction surveys, complaints, and suggestions for quality improvement opportunities.
• Participate/support chronic care management initiatives.
• Assists Quality Coordination, Operations staff and the Executive Management Team in the review, revision and formulation of appropriate policies and procedures to guide issues of compliance
• Coordinate with appropriate staff to ensure understanding of policies defining compliance initiatives, as stated in the Compliance Plan.
• Coordinate the Risk Management Program as outlined in the Risk Management Plan
• Oversee or conduct risk assessments, walk through inspections, adverse event reports, past accreditation or licensing surveys, medical records, risk analysis methods to identify, evaluate, prevent and control the risk of injury or loss.
• Participate in root-cause analysis of occurrences or possible occurrences.
• Report Risk Management activities to the Quality Improvement Committee, which is chaired by the Medical Director
• Oversee the data collection and processing, information analysis, and generation of statistical trend reports for the identification and monitory of adverse events, and effectiveness of the risk management program.
• Assist the Medical Director in the Quality Assurance Committee meetings.
• Assess and ensure goals set by Quality Assurance Committee are met in a timely manner.
• Update and revise policies and procedures as needed in conjunction with the Medical Director, in support of quality initiatives, risk management, and compliance with HIPAA standards and regulatory changes.
• Assist with the initiative to obtain and maintain PCMH status with ongoing activities for related health care home initiatives.
• Motivate and inspire others by setting a positive example, solicit and/or provide innovative ideas from staff, co-workers and physicians.
• Show accessibility to physicians, staff and management, maintaining open lines of communication, providing appropriate written documentation as needed, while acting as a liaison between the CHCGD centers, physicians and staff.
• Remains open to feedback for improvement, willingness to change, and be flexible.
• Coordinate and/or conduct the clinical training of staff, including MOBI and CLIA.
• Assist with and/or conduct EHR/PM system training for staff and providers.
• Educate staff on Quality Improvement concepts and tools.
• Engage staff in participation of quality improvement activities.
• Monitor and direct OSHA activities and training.
• Comply with TB Control Plan, including PPD testing.
• Perform other duties as assigned.

Required Skills or Abilities:

• Working knowledge of Quality Improvement, Risk Management and Compliance processes
• Demonstrate initiative, ability to work with others and good professional judgment
• Able to work independently and organize time effectively.
• Excellent written and verbal communication skills.
• Strong organizational skills and attention to detail.
• Able to work with confidential information.
• Proficiency in MS Office products, such as Word, Excel, Power Point and Outlook.
• Working knowledge of EMR
• Coaching, mentoring and teaching skills
• Ability to relate well to people from diverse ethnic and cultural backgrounds.

Required Knowledge, Experience or Licensure/Registration:

• Graduate of LPN or Registered Nursing program with current licensure or related healthcare degree preferred; BSN preferred.
• Current CPR certification
• CPHQ certification preferred.
• Ambulatory, CHC or primary care experience preferred. Familiar with standard concepts, practices and procedures within healthcare office setting.
• Previous experience with clinical quality assurance required.