POSITION TITLE: Quality & Risk Management Director
STATUS: Full-Time / Exempt
RESPONSIBLE TO: VP for Medical Services
GENERAL DESCRIPTION: In cooperation with the Vice President for Medical Services (VPMS) and Affiliate Medical Director (AMD), the Quality and Risk Management Director (QRMD) is responsible for the developing, implementing and managing all QRM activities related to the PPHS medical services program.
DUTIES AND RESPONSIBILITIES:
Develop, implement, monitor and report on PPHS Quality and Risk Management (QRM) annual workplan, quality indicators, and schedule of audits and activities.
Develop audit tools and coordinate timely completion of audits and corrective actions plans. Support health centers in meeting at least 90% criteria for all audits, or greater, as required.
Coordinate the timely completion of all Incident Reporting, tracking, trend analysis, and corrective action plans. This includes incidents and adverse events that PPHS tracks and those that are reportable to ARMS.
Participate in the development of changes to policies, procedures and tools that could minimize occurrences and improve quality and safety wherever possible.
Prepare required reports to ARMS, monthly reports to VPMS and AMD, and an annual report on program accomplishments for presentation to affiliate senior leadership and Board.
Develop, implement, monitor and report on PPHS Infection Prevention Program, consistent with local, state, national standards and regulations, including tools, resources needed for initial and ongoing staff training, competency evaluation and monitoring for compliance.
Work with AMD and VPMS to develop, maintain and publish the following policy and procedure manuals, in compliance with PPFA medical standards and guidelines, ARMS guidelines, CLIA, OSHA, CDC and APIC standards, state Boards of Nursing, Medicine and Pharmacy regulations, and other local and state regulations, as applicable.
PPHS Quality & Risk Management Manual
PPHS Medical Manual
PPHS Infection Prevention Manual
PPHS Laboratory Manual
Act as a liaison between AMD and medical staff to provide clarification and interpretation of departmental policies and procedures.
Assure annual review of policies and procedures.
Ensure health center and lab compliance with PPFA, ARMS, OSHA, CLIA, and State licensing requirements, including required policies, procedures, trainings, in- services, and reporting.
Seek PPFA approval or waivers for new protocols.
Participate in planning for new medical services, products and programs.
Coordinate orientation to medical services for new clinicians, physicians, health center managers, including QRM training.
Coordinate clinical evaluations of new clinicians & physicians as part of the annual performance review, or more often as needed.
Assist with the development and maintenance of health center staff training resources.
Serve as a medical information resource to affiliate staff; provide medical staff training as needed.
Measure, evaluate and report on client satisfaction.
Coordinate the QRM component of departmental meetings. Participate in Health Center Manager meetings, Clinician Workgroup meetings, Medical Services Leadership Team meetings and other staff meetings as needed.
Other duties as assigned by VPMS.
Education: RN/LPN/NP OR PA, Bachelor’s degree, preferably in health-related field;
Experience: Minimum of 3 years experience in a healthcare environment, preferably GYN/ Family Planning; Demonstrated project management experience; Excellent organizational, verbal and written communication skills; Attention to detail; Proficiency in MS Windows and MS Office products including Outlook, Word, Excel and Powerpoint; experience with Adobe and MS Sharepoint preferred; Ability to effectively utilize clinical software programs for data entry and reporting; Ability to respond appropriately to changing situations; Ability to work on multiple projects concurrently; Ability to self- motivate and work independently; Commitment to departmental goals regarding quality, productivity and customer service;
Personal: Understanding of and commitment to PPHS goals and mission; Excellent written and oral communication skills; Ability to work independently and as part of a team.
Other: Required to read, comprehend and analyze data daily. Must input and retrieve data daily. Must perform written communication and use office equipment daily. Required to communicate with staff and public in person and via telephone daily. Use of automobile may be required.
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