Clinical Quality Director

The Clinical Quality Director is responsible for all facets of the corporation’s performance improvement, risk management and Joint Commission (JCAHO)/Accreditation Association for Ambulatory Health Care (AAAHC) accreditation programs. Within each of these programs, there are elements of responsibility that are critical to the operation of Take Care Health Centers. The incumbent plans, organizes, directs, and implements performance improvement policies related to healthcare delivery at Take Care Health Centers. Direction is provided in compliance with either AAAHC or JCAHO standards for accreditation, and etc. The goals of this position are to improve patient outcomes and healthcare delivery through the establishment of an integrated and collaborative organizational approach to performance improvement; reduce the incidence of potentially compensable events through the establishment of an aggressive and comprehensive patient safety program; and, to provide for the most efficient use of clinical resources in the pursuit of quality patient care.

Essential Functions:

•Plans, organizes, directs, and manages the Take Care Health Systems (TCHS) Performance Improvement program, ensuring compliance with legal and regulatory requirements. Researches, interprets, analyzes and applies Joint Commission standards for accreditation.
•Develops, plans, organizes, directs and manages the TCHS Risk Management program. Responsible for developing systems which support the prevention of potentially compensable events among patients and visitors, and injuries to staff at the centers. Develops programs to comply with JCAHO and AAAHC accreditation standards for risk management, patient safety, patient rights and responsibilities, and organizational ethics.

•Administers accreditation and compliance programs for Take Care Health Systems. Serves as primary organization liaison to the accrediting organization(s) for scheduling accreditation surveys. Prepares applications for accreditation surveys, and updates applications as organizational circumstances change. Directs the facility’s involvement in the JCAHO ORYX program if required.

•Administers management support programs which fulfill the organization’s requirements for strategic planning and data management. Directs the collection of organization data to support the development of performance indicators under the corporation strategic plan.
REQUIREMENTS
Qualifications:

1. RN, NP, MD or DO training and licensure.

2. Required - previous experience and knowledge of regulations and standards of regulatory and credentialing groups and directives including requirements for accreditation promulgated by the Joint Commission on Accreditation of Healthcare Organizations, National Committee on Quality Assurance, and Accreditation Association for Ambulatory Health Care, Inc. Previous experience working on an organizational survey team is preferred.

3. Proven performance in the ability to gather, analyze, and make recommendations based on complex and diverse data. Knowledge of techniques to include: root cause analysis, cause and effect analysis, failure mode and effects analysis, and development of action plans.

4. Knowledge of safety, security, and claims management, and judge advocate claims investigatory processes. Knowledge of medical liability, patient policies, and a wide range of administrative laws, regulations and standards associated with the administration and adjudication of claims. Risk management experience within a healthcare setting required.

5. Ability to prepare and conduct training sessions for educating all levels of healthcare staff in areas of quality management and performance improvement.

6. Proficiency in technology to include MicroSoft Office products, as well as electronic medical record systems required.

7. Superior verbal and written communications skills.

8. Extremely motivated and self-directed