Job Description

Primary Accountability

The Director of Quality Improvement & Risk Management is responsible for the development, implementation and monitoring of quality improvement and assurance programs and programs that identify safety and security risks associated with the environment of care for Family HealthCare Network in such a way that promotes the highest level of quality and safety in the services provided in the organization.

of Primary Responsibilities

1. Provide overall management and direction to departmental/division staff.
   1. Responsible for performance management of departmental employees, including all managers, supervisors, and employees in the department, including recognition, performance evaluations, formal coaching and counseling, and making decisions or recommendations regarding necessary disciplinary actions.
   2. Responsible for recommending hiring or firing and the advancement and promotion of managers, supervisors, and employees in the department, or any other change status of manager, supervisors, and employees in the department.
   3. Demonstrates core leadership behaviors and team one approach.
   4. Demonstrates a high level of emotional intelligence.
   5. Creates a culture of accountability and excellence.
   6. Drives execution and innovation.
   7. Ensures division alignment with organizational culture and strategic vision.
   8. Ensures the development and successful execution of an action plan across the assigned employee base to support the organization's strategic direction and the achievement of operational goals for assigned departments/divisions, effectively leading change when necessary.
   9. Empower staff through effective communication and talent development.
   10. Ensures team members of all assigned areas of responsibility are fully functional and performing at a world-class level.
   11. Ensures development of department/division managers and supervisors receive instruction/training that is in compliance with a training plan, including on-the-job training to develop department employees. Works with manager and/or supervisor to ensure necessary remediation is taken with department/division employees assigned.
   12. Assists with developing assigned departmental/division budget(s) and monitors the budget to ensure expenses do not exceed the budget.
   13. Ensures regulatory compliance for assigned departments/divisions and compliance with all workflows, policies, and procedures.
   14. Recommends workflow, policy, and procedure changes based on observations from performance metrics, outcomes, and feedback from assigned leadership team members.
   15. Ensures department maintains compliance with all employees related reporting and tracking.
2. Responsible for overseeing the quality improvement, risk management, patient safety, patient satisfaction survey, emergency preparedness, injury and illness prevention, and infection control programs for the Network.
   1. Ensures relevant policies are in compliance with regulatory and accrediting bodies.
   2. Ensures reporting tracking and monitoring mechanisms are in place to ensure ongoing compliance.
   3. Reports regularly to the appropriate committees for ongoing quality improvement and risk mitigation.
3. Provide expertise related to quality improvement and risk management.
   1. Serves as a liaison and quality education resource for other departments.
   2. Serves as or designates a delegate on both standing and ad hoc committees whose
   3. activities related to quality improvement.
   4. Maintains working knowledge to ensure compliance of and administratively support QI team on subject matter related to QI/QA activities, including but not limited to:
      1. Health Resources and Services Administration (HRSA) regulation;
      2. The Joint Commission Standards;
      3. National Committee for Quality Assurance (NCQA) Patient-Centered Health Home certification requirements;
      4. Meaningful Use requirements and reporting;
      5. Federal Tort Claims Act (FTCA) coverage and other risk mitigation topics;
      6. Emergency preparedness, and
      7. OSHA, Title 22, and other regulatory entities.
   5. Assists in the creation and review of QI and risk management policies and procedures annually.
4. Responsible for ensuring the organization meets accreditation and regulatory standards, fulfills federal and state reporting requirements and provides the highest quality care in a safe, timely, and patient-centered manner.
   1. Responsible for FHCN policy and procedures manual and ensures an annual review.
5. Coordinates the development of, reviews, updates, and oversees the implementation of survey systems, audit tools, and programs that gather data and provide necessary quality-related information to Health Center staff and other teams. Examples include, but are not limited to:
   1. Quality of clinical performance measures;
   2. Operational efficiency measures;
   3. Effectiveness of continuity of care;
   4. Hazard and Safety audits; and
   5. Tracking and analysis of risk events and their mitigation.
6. Responsible for maintaining insurance affairs for FHCN.
7. Ensures application, maintenance/renewal, and compliance with general liability, auto, property, and malpractice insurance coverage, including FTCA and gap insurance programs.
8. Ensures implementation and adherence to risk plans.
9. Ensures compliance with transportation fleet registration and certification of personnel employment eligibility.
10. Performs other duties as assigned.

of Primary Attributes

Professional & Technical Knowledge:

1. Possesses specific advanced knowledge skills, including written and verbal communication skills, computational, computer, and technical skills, and mathematical knowledge acquired through the completion of a bachelor’s degree program with a recognized major or a comparable level of business/industry acumen.
2. Performance of the job's duties and responsibilities requires the equivalent of formal training in quality improvement analytics, usually in the form of a major involving health care or other analytics or as part of a bachelor’s degree program.
3. Minimum of six (6) years of leadership experience or seven (7) years of progressively greater responsibility, including significant contributions to projects and initiatives that demonstrate leadership skills.
4. Knowledge of regulatory requirements, including HIPAA, Title 22, CDPH, and OSHA, and accreditation processes of the Joint Commission preferred.

Technical Skills:

1. Ability to create highly complex documents in Microsoft Word, including linking multiple files and embedding objects linked to other documents.
2. Ability to use advanced functions of Microsoft Excel, such as creating and managing databases, including creating standardized reports or linking multiple worksheets and workbooks.
3. Ability to develop sophisticated presentations in Microsoft PowerPoint, including embedded objects, transitions, and other elements.

Licenses & Certifications: Risk Management certification must be completed within the first year of employment through organizations such as the American Society for Healthcare Risk Management (ASHRM), California Primary Care Association (CPCA), or certification from another accredited agency may be considered.

Communications Skills:

1. Job duties require the employee to effectively communicate, verbally and in writing, their opinions and extrapolations of information they collect and synthesize/analyze.
2. Responsible for resolving conflicts arising from disagreements between employees, between employees and customers/clients, or with the public, other legal entities, or governmental authorities.
3. Compiles, analyzes and prepares information in effective written form, including correspondence, reports, articles, or other documentation.
4. Effectively conveys technical information to non-technical audiences.

Physical Demands: The physical demands described in this job description are representative of those that an employee must meet to successfully perform the essential functions of this position. Reasonable accommodation may be made to enable individuals with disabilities to perform essential functions.

While performing the duties of this position, the employee is regularly required to sit and use repetitive hand movements to type and grasp. The employee is frequently required to stand or walk and must occasionally lift and/or move up to 20 pounds.

Pay Scale:

Min Salary Rate: $111,597.05

Max Salary Rate: $178,555.28