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Quality Improvement/Risk Management Director (FT)

Lincoln Community Health Center, Inc.
Durham, NC Full Time
POSTED ON 4/3/2024
Lincoln Community Health Center, Inc.
 
Job Title: Quality Improvement Director/Risk Management Director.
FLSA Classification: Exempt.
Department: Medical Department.
Date: 5/13/22.
Reports To: CMO.
   
Lincoln Community Health Center, Inc. (LCHC), mission is to provide primary and preventive health care in a courteous, professional and personalized manner.  Key requirements for any position are our “Core Values”:  courtesy, respect, quality, accessibility, teamwork, and continuous improvement.
 
Lincoln Community Health Center is an ambulatory primary care center. The Center is situated within the community in such a way that it may serve as a resource to patients, employees, and the surrounding community, as applicable, during times of emergencies and disasters. As such, Lincoln has an obligation to plan ahead and train its staff for these possible incidents so emergency response procedures can be implemented rapidly and seamlessly to minimize any negative impact on patients or the community. This emergency and disaster preparedness should include identifying risks and considering potential emergencies and developing strategies for preparation and training. When possible, Lincoln will collaborate with relevant community partners for emergency and disaster planning and response.

Position Description/Occupational Summary:
This position is responsible for helping to oversee and to coordinate all Quality Improvement Activities in the organization. The Quality Improvement Director (QID) works directly with Senior Leadership and others in leadership roles at LCHC to identify, and to implement, strategies to assure compliance with performance improvement requirements of the Joint Commission and the Primary Care Medical Home (PCMH) certification, HRSA and UDS, FTCA, NC Department of Health and Human Services, and Meaningful Use certification.  In addition, the QI Director lead, or assists with, workgroups and projects designed to promote continuous quality improvement at Lincoln Community Health Center.  The Quality Improvement Director is responsible for overseeing the Center’s Risk Management Program which includes but is not limited to chairing the Risk Management Committee, facilitation of Audit Committees, reviewing and responding to potential clinical and organizational risk and maintaining an effective Risk Management program.
 
Minimum Qualifications/Education:
  • Masters of Science Degree in Nursing (MSN) or related field required.  
  • Bachelor’s Degree in Nursing and license to practice in NC required.
  
Experience:
  • A minimum of five years nursing experience including significant administrative experience is required.
 
Additional Knowledge, Skills and Abilities Required:
  • Knowledge of Health care delivery including elements of patient safety and performance improvement is required.  Also required is an ability to communicate effectively and with clarity, accuracy, and tact, with patients, medical providers, ancillary staff, and partner agencies.  
  • Ability to collect, interpret, and report on data to facilitate clinical operations and regulatory compliance.
 
Additional Skills Preferred:
  • Expert knowledge of medical office operations.  
  • Familiarity with role of FQHCs in the community.
 
CERTIFICATION(S)/LICENSURE: 
License to practice Nursing in North Carolina required.
 
Physical Requirements: 
The physical demands and work environment described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Work involves sitting for long periods of time, walking, climbing stairs and a step stool, kneeling, stooping, talking, hearing, using hands to handle, feel or operate objects, tools, or controls, and reaching with hands and arms. Vision abilities required by this job include close vision and the ability to adjust focus.

The noise level in the work environment is usually moderately quiet. The employee must have the ability to travel among various worksites. 

Key Responsibilities/Duties:
In cooperation with Senior Leadership:
  • Oversee the development and implementation of a comprehensive quality improvement program to include analysis and regular data reporting for all quality improvement initiatives.  Help to assure at LCHC a culture of continuous improvement.
  • Serve as the Chairperson and facilitate the overall Quality Improvement Committee Activities and provide strategic oversight for all Committee activities. Assure that Committee work is satisfactorily accomplished on agreed-upon timelines.
  • Collaborate directly with Clinical Leadership and key departments to meet performance improvement requirements for HRSA compliance, UDS reporting, and FTCA compliance, for Meaningful Use certification, and for Primary Care Medical Home accreditation
  • Serve as the PCMH Champion and direct activities to assure compliance.
  • Oversee and coordinate the development of policies and procedures relevant to clinical quality.  Assure that these are appropriately updated, communicated to all relevant staff, and quickly accessible.
  • Provide oversight and serve as a resource for all Patient Safety Goal activities; facilitate all reporting activities for near miss and sentinel events and maintain data.
  • Oversee data collection, analysis, and reporting on the patient experience at LCHC, including survey responses and other patient feedback.
  • Provide education to all levels of staff regarding compliance with regulatory agencies, Joint Commission and patient safety standards.
  • Maintain collaborative relationships with Chiefs of Services to facilitate continuous performance improvement for the organization, to meet HRSA, accreditation, and other standards, and to meet  patient safety goals
  • Develops and maintains budgets for the QI Department to include training needs and clinical supplies
  • Manage the Risk Management program by overseeing risk management activities, performing risk analysis, establishing Audit committees and chairing the Risk management Committee.
  • Responsible for the Risk Management Plan and ensuring that Staff receives appropriate training in conjunction with the Human Resources Department.
  • Upon request of Senior Leadership, perform other related duties.  
 
LCHC’s Core Values:
  • Courtesy.
  • Respect.
  • Quality.
  • Accessibility.
  • Teamwork.
  • Continuous Improvement.
 
Direct Reports: N/A.

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$132,356 to $197,090
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