Director of QI and Risk Management

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.

Description 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 st