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 and 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 RESPONSIBILITIES: Develops and implements performance measures to improve processes and clinical outcomes. Analyzes, develops, and implements improvement activities, including but not limited to policies and procedures to increase quality and/or compliance rates as measured by nationally standardized benchmarks and definitions. 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. Monitors all new and existing continuous quality improvement (CQI) initiatives, providing comprehensive analyses and improvement ideas and integrating those concepts in the short- and long-term plans of the SNHS. Coordinates the development 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. Participates in developing and implementing interventions, including provider report cards and dashboards as related to improving patient care and clinical outcomes. Determines compliance and quality metrics and establishes a system for tracking them. Reviews all incoming inquiries 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. Tracks status of Compliance questions/requests by maintaining the Compliance Status Document and ensuring team members provide regular and timely updates. Compiles, reviews, and evaluates quality data on Purchased/Referred Care vendors to ensure patients receive the highest quality of care from outside providers. Coordinates CQI committee meetings (at least quarterly) with administration, providers, staff, and the Board of Directors Quality Improvement Committee. Provides recommendations on policies and processes to improve the overall quality of care provided. Keeps internal stakeholders (QI, Compliance, ELT teams) informed regarding deadlines, turnaround targets, and status updates. Participates in data extraction and preparation for submission of required data analysis and conclusions to oversight and/or accrediting bodies, including to the CEO and the Board of Directors for monthly, quarterly, and annual reporting. Responsible for the implementation, monitoring, and management of compliance controls, procedures, and operational processes for the Compliance Program. Assists with monitoring adherence to departmental processes. Coordinates in the preparation and completion of regulatory, quality, and compliance documents. Coordinates regulatory projects by tracking progress, scheduling meetings, maintaining Regulatory Action Tracker, and facilitating communication. Identifies areas of noncompliance and coordinates with management and employees to develop improvement plans. 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. Performs, or assists in the performance of, investigations of compliance-related violations including response and resolution. Identifies preventative care areas with declining or plateauing compliance rates over time, including root cause analysis for contributing factors. Tracks and monitors incident reports and patient complaints to ensure patient safety and improve satisfaction. Evaluates and reports compliance rates on a quarterly basis. Attends all mandatory staff meetings and in-services, including training to stay current in position and/or department. Follows all policies and procedures of the department, Seneca Nation, and SNHS. KNOWLEDGE, SKILLS, & ABILITIES: Knowledge of principles and policies of quality improvement and risk management programs including program structure, monitoring, evaluation, and reporting tools and processes (e.g. PDSA cycles, A3 summaries, statistical analysis and charting, survey methodology, trend analysis and control limits, etc.). Knowledge of mathematics and relevant statistical techniques and ability to perform computations thereof. Thorough understanding, knowledge, and application of research, analysis, and assessment of compliance with federal regulations related to Medicare, Medicaid, HIPAA, Affordable Care Act, and other government laws and programs related to the healthcare industry. Knowledge and understanding of the principles, procedures, and associated regulations and standards for the delivery of rural, community-oriented health care delivery systems. Familiarity with Indian Self-Determination contracting and the IHS system. Requires a professional image/demeanor as well as an extremely responsible working attitude with oral and written communication skills being an absolute necessity. Individual must exhibit the highest level of integrity and ethics. Ability to maintain a high degree of confidentiality and discretion. Familiarity with the mandatory reporting requirements under the Indian Child Protection Act, with regards to suspected incidence of child abuse or child neglect. Excellent time management skills with a proven ability to meet deadlines. 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 in Nursing, Public Health Administration, Health Administration, or related Health Service degree from an accredited university or college with five (5) years of healthcare experience in an ambulatory setting with exposure to and involvement with provider performance improvement activities, required. Master's degree in Nursing, Public Health Administration, Health Administration, or related Health Service degree from an accredited university or college with five (5) years of healthcare experience in an ambulatory setting with exposure to and involvement with provider performance improvement activities, preferred.
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