Director of Quality

BASIC FUNCTION:

The Director of Quality is responsible for managing risk, ensuring compliance, best practices and improving overall performance and quality at the Seneca Nation Health System (SNHS).  The incumbent will work closely with administration and clinical leadership to establish a vision an direction for quality improvement and compliance.  Responsible for the management of the Health Planning Office and direct supervision of two direct reports.  Serves as the SNHS Compliance Office.

GENERAL RESPONSIBILTY:

1. Develops and implements performance measure to improve processes and clinical outcomes.
2. Analyzes, develops, and implements improvement activities, including but not limited to policies and procedure to increase quality and/or compliance rates as measure by nationally standardized benchmarks and definitions.
3. Participates in and leads (as required) the education of SNHS employees and the Board of Directors on risk management and quality performance indicators selected by the organization, focusing on the requirements and implications of these measures for safe clinical practice.
4. Monitors all new and existing CQI initiatives, providing comprehensive analyses and improvement ideas and integrating those concepts in the short- and long-term plans of the SNHS.
5. Coordinates the developments of quality assurance processes to ensure that evidence-based best practices are utilized throughout the system and maintains quality assurance/quality improvement (QA/QI) process reviews uniformly throughout the system.
6. Participates in developing and implementing interventions, including provider report cards and dashboards as related to improving patient care and clinical outcomes.
7. Determines compliance and quality metrics and establishes a system for tracking them.
8. Reviews all incoming inquires and other compliance and quality requests to ensure all necessary information is included, assess the priority of each question/request, and address questions/complete requests or assign to employees when appropriate.
9. Compiles, reviews, and evaluates quality data on Purchased/Referred Care vendors to ensure patients receiving the highest quality of care from outside providers.
10. Coordinates Continuous Quality Improvement (CQI) committee meetings (at least quarterly) with administration, providers, staff, and the Board of Directors CQI Committee.
11. Provides recommendations on policies and processes to improve the overall quality care provided.
12. Keeps internal stakeholders (QI, Compliance, ELT teams) informed regarding deadlines, turnaround targets, and status updates.
13. Participates in data extraction and preparation for submission of required data analysis and conclusions to oversight and/or accrediting bodies, including the CEO and the Board of Directors for monthly, quarterly, and annual reporting.
14. Responsible for the implementation, monitoring, and management of compliance controls, procedures, and operational processes for Compliance Program.
15. Follows all policies and procedures of the SNHS. Follows all policies of the Seneca Nation. Assists with monitoring adherence to departmental processes.
16. Coordinates in the preparation and completion of regulatory, quality and compliance documents.
17. Coordinates regulatory projects by tracking progress, scheduling meetings, maintaining Regulatory Action Tracker, and facilitating communication.
18. Identifies areas of noncompliance and coordinates with management and employees to develop improvement plans.
19. Performs and/or coordinates random internal audits for units/departments to ensure compliance with laws, policies, procedures, and regulations at all levels of the SNHS.
20. Performs, or assists in the performance of, investigations of compliance-related violations including response and resolution.
21. Tracks status of Compliance questions/requests by maintaining the Compliance Status Document and ensuring team members provide regular and timely updates.
22. Identifies preventative care areas with declining or plateauing compliance rates over time, including root cause analysis for contributing factors.
23. Tracks and monitors incident reports and patient complaints to ensure patient safety and improve satisfaction.
24. Evaluates and reports compliance rates on a quarterly basis.
25. Attends all mandatory staff meetings and in-services, including training to stay current in position and/or department.

KNOWLEDGE, SKILLS, & ABILITIES:

• Excellent verbal and written communication skills.
• Excellent interpersonal and negotiation skills.
• Excellent time management skills with a proven ability to meet deadlines.
• Strong analytical and problem-solving skills.
• Ability to prioritize tasks and to delegate them when appropriate.
• Ability to adapt to the needs of the organization and employees.

QUALIFICATIONS:

• Bachelor’s degree or equivalent professional experience (5 years) required.
• Master’s degree and five (5) years of managerial/supervisory experience preferred.
• Five (5) years of quality management experience as a supervisor or manager in a large hospital, academic medical center, outpatient health care setting, or Indian Health Service (IHS) / tribal health.
• Familiarity with project management concepts; experience managing deadlines.
• A valid NYS driver’s license is required.