Director of Quality and Clinical Education

PACE SEMI QUALTIY & Clinical Education DIRECTORPURPOSE: Under the direction of the Chief Clinical Officer, the Director of Quality in partnership with the medical director is accountable for developing, implementing and monitoring all goals and activities related to Quality and Clinical Education for PACE Southeast Michigan (SEMI). The Quality & CE Director supports continuous quality improvement (CQI) in the quality of care and service provision. This is accomplished by assisting all key stakeholders to develop and maintain quality initiatives that are focused on the continuum of care processes, which aim to maximize the outcomes for all PACE participants Develops and implements the annual quality improvement (QI) PlanOversees QI activities and teamsOversees all required quality reporting to CMSEnsuring quality healthcare for all patients.Managing risk and ensuring compliance.Controlling infection and improving overall performance.Representing quality and patient safety to the organization and external entities.Collaborating with other leaders for the coordinating of staff workflow and performance outcomes.Partners with Learning & Development Director to plan and implement required clinical staff education, training, and coordination to ensure a highly competent qualified clinical staff.Identifies and supports relationships & partners required to build a strong pipeline of clinical staff.Serving as the subject matter expert for quality and healthcare regulations.Conducting research and development to support new or revised business processes.Collaborating with external vendors and internal departments to improve healthcare quality metrics.Participates and partners with Technology Clinical Solutions specialists to advance and innovate care.Leading and directing care management activities, ensuring adherence to clinical protocols and regulatory standards5.Collaborates with the medical director, learning & development director and regulatory compliance director for to assure adherence to Federal and State regulatory requirements.Facilitates quality assurance-related communication between contract facilities and PACE Interdisciplinary TeamsThe quality director's approach to CQI is fostered by a process that includes the following key components: identification, investigation, implementation, improvement and monitoring. Implementation of these basic concepts will lead to the successful development and execution of a quality plan that not only meets regulatory requirements but supports the efforts of the PACE organization toward implementing a formalized and systematic approach to CQI.The quality director plays a significant role and engages leadership, staff, providers and other key stakeholders in QI efforts. A collaborative approach to QI, along with the use of a QI model (i.e., PDCA), ensures the involvement of individuals who are responsible for the work to be measured; identification of critical work processes and requirements; identification of critical results desired, with alignment to regulatory requirements; development of measurements for the critical work process or results; and establishment of performance goals, standards or benchmarks.Prevention ProgramsDevelop proactive risk assessments, which can include the use of failure mode and affects analysis, system analysis and other tools.Develop systems to oversee adverse events, near-misses and potentially unsafe conditions.Develop and implement event reporting policies and procedures.Ensure the collection and analysis of data to monitor the performance of processes that involve risk or may result in serious adverse events (e.g., medication use processes).Continuous Development of the Risk Management ProgramMonitor the data collection and processing, information analysis, and generation of statistical trend reports for the identification and monitoring of adverse events, claims, finances, and effectiveness of the risk management program.Analyze data collected on adverse events, near-misses and potentially unsafe conditions.Provide feedback to providers and staff; and use this data to facilitate systems improvements to reduce the probability of the occurrence of future related events. Root-cause analysis and systems analysis can be used to identify causes and contributing factors in the occurrence of such events.Ensure compliance with data collection and reporting requirements of regulatory agencies.Facilitate and ensure the implementation of patient safety initiatives, such as improved tracking systems for medication safety systems and falls prevention programs.Facilitate and ensure provider and staff participation in educational programs on patient safety and risk management.Knowledge, Skills, and Abilities Required Master's degree Required.Registered Nurse. Must provide current State of Michigan registrationlicense, as applicable.Minimum of three - five years progressively more responsible experience in health care. Prior experience in quality assuranceimprovement management required. Experience in a leadership capacity preferred.Excellent verbal, written and interpersonal skills.Ability to work with diverse populationsgroupsteams.Strong analytical skills and attention to detail. Working knowledge of computer software for word processing, format development and spreadsheet management.Must have one (1) year of experience with a frail or elderly population

Created: 2025-02-23