Director of Quality Improvement - FMG - Central Administration
Catholic Health Initiatives 179 reviews - Tacoma, WA

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Job Summary:
This job is responsible for the development, management and evaluation of strategies, standards, programs and practices addressing quality, patient safety and delivery of patient care for the Franciscan Medical Group (FMG) in accordance with the overall business objectives, and applicable regulatory requirements. This position is responsible for the clinical performance standards, quality assurance, standardization and staff competency. Manages resources to facilitate and ensure efficient delivery of patient care. Position is responsible for meeting performance expectations in the areas of quality care, patient safety, service excellence, access, financial performance, grants, and resource utilization in area of responsibility, which includes multiple service lines within the medical group and population healthcare/chronic disease management programs. This position works closely with the CMO and Medical Director of Quality to improve the overall quality of patient care provided by the organization.

Essential Job Functions:
Support Medical Director of Quality, Quality Committee and/or Executive Committee Quality Sub-Committee in implementing quality initiatives including maintenance of clinical registries and monitoring of quality and outcome measures. Institutes programs that improve quality and patient safety, and report results to FMG leadership as well as applicable State and Federal agencies. Work with leadership and medical providers to address any quality or safety deficits. Coordinate and organize monthly Quality Sub-Committee meeting in conjunction with the Medical Director of Quality. Develop and facilitate standardization, staff competency measurement and communication between clinical support staff and medical leadership. Assists in development and oversight of clinical medical staff i.e. nursing, medical assistants' credentials and competencies and performance remediation; including participation in and hiring and disciplinary process as appropriate. Identifies and seeks opportunities for grants related to quality and leads project implementation.

Guide overall development and implementation of population healthcare plan. Develop and implement ongoing education and training programs focused on effective population healthcare/chronic disease management. Work with physicians for health status evaluations and improvement, clinical pathway, outcomes criteria development and development of screening tools to identify high risk patients. Assist in design and implementation of information systems needed to support the plan. Network with payors and other providers of services to promote development and coordination of continuum of care efforts. Evaluate plan effectiveness and recommend revisions where appropriate.

Oversight and monitoring of FMG Employee Health Program. Provide tracking of TB Surveillance Program and New Employee Health Screening.

Develops and administers annual operating budget, identifies resources needed to accomplish performance objectives, exercises cost control to stay within budget; identifies variances and develops action plan to address; keeps SLT appraised of budgetary impact issues. Manage and negotiate agreements with vendors to ensure smooth operation and consistent return on investment. Manages the maintenance of application systems and assures the effective integration and utilization of installed capability

Reviews & audits all potential acquisitions to ensure compliance with applicable Federal, State and local laws and regulations. Updates FMG leadership and develops remediation plan for potential acquisitions if deficiencies are found.

Develops and maintains a "Minimum Standards for Risk, Compliance and Quality Guide" that outlines standards for medical, legal, information technology processes that are required of all current clinics and potential acquisitions.

Cultivates and maintains professional relationships with primary customers including medical directors, physicians, physician groups, patients, supply vendors and external entities to foster opportunities for improvement in quality metrics, enhanced customer service and to positively impact core clinic measures.

Develop, implement and monitor quality assurance programs, systems and initiatives impacting the entire organization to facilitate performance and process improvements in keeping with strategic objectives and regulatory requirements. Oversight and monitoring of Patient Satisfaction data; works with Patient Satisfaction vendor to consult and provide best practices and strategies for FMG.

Ensures compliance with legal and regulatory requirements, monitors the effectiveness of current practices and procedures in producing desired results. Keeps abreast of regulatory requirements, professional standards and competitive industry practices, as well as organizational initiatives with potential to impact current strategies. Oversight and monitoring of the FMG Safety Program to meet WAC, OSHA and WISHA regulations. Develops and provides tools to clinic staff to assure annual safety training is completed for Blood Borne Pathogen Exposure Control, Hazard Communication, TB Exposure Control and general safety topics.

Responsible for the development, standardization, implementation and monitoring of the clinical operational policies and procedures within the Franciscan Medical Group. Ensures that compliance with regulatory, accreditation and other quality organizations is maintained. Responsible for the competency of clinical support staff through education and oversight. Assure comprehensive orientation and training of clinical support staff.

Develops strategic and tactical plans to include both short and long-term business planning with accountability for achievement of plan objectives; develops and oversees programs and projects to develop and implement business objectives anticipating current and future needs. Oversees and evaluates the effectiveness of the FMG Patient Advocate and Peer Review Programs; makes peer review reports to executive team, medical staff leadership and governance bodies as appropriate; serves as staff to FMG Peer Review Committee.

Plans, directs and evaluates the work of staff; complies with human resource management policies and procedures; ensures adequate staffing levels, allocates resources; ensures that employees are qualified, trained and meet customer service standards; makes employment decisions, utilize best practices for performance management to include rounding, completes performance appraisals; coaches and develops staff and addresses performance concerns.

Qualifications

Education/ Work Experience:
High School Diploma or GED required.

Bachelor's degree in Business Administration or health services administration required. Masters degree preferred.

Registered Nurse license in the state of WA; BSN required.

Progressive responsibility within a managerial position and business development/ performance improvement experience required.

Seven to ten years work experience in a progressive management responsibility position as a registered nurse, with at least two years of ambulatory care experience.

Experience in a decision making, business administration environment also required.

Licensure/Certification:
Registered Nurse license in the state of WA; BSN required.

Current driver's license valid in the state of Washington or other evidence of equivalent mobility.

Additional Responsibilities:
Demonstrates a commitment to service, organization values and professionalism through appropriate conduct and demeanor at all times.

Adheres to and exhibits our core values:
Reverence:
Having a profound spirit of awe and respect for all creation, shaping relationships to self, to one another and to God and acknowledging that we hold in trust all that has been given to us.

Integrity:
Moral wholeness, soundness, uprightness, honesty and sincerity as a basis of trustworthiness.

Compassion:
Feeling with others, being one with others in their sorrows and joys, rooted in the sense of solidarity as members of the human community.

Excellence:
Outstanding achievement, merit, virtue; continually surpassing standards to achieve/maintain quality.

Maintains confidentiality and protects sensitive data at all times.

Adheres to organizational and department specific safety standards and guidelines.

Works collaboratively and supports efforts of team members.

Demonstrates exceptional customer service and interacts effectively with physicians, patients, residents, visitors, staff and the broader health care community.

Catholic Health Initiatives and its organizations are Equal Opportunity Employers CB\

Job

Management

Primary Location

WA-Tacoma-Fmg-Central Administration

Shift

1

Scheduled Hours per 2-week Pay Period

80

Weekends Required

None

Status

Full Time

About this company
179 reviews
For Catholic Health Initiatives (CHI), returning sick people to good health is more than a business -- it's a mission. Formed in 1996...