Job Title:             Quality Improvement Specialist

Reports To:         Director of Operational Quality Improvement

Job Status:      Exempt                    Non-Exempt

 

Summary

It is the responsibility of the Quality Improvement Specialist to assemble assigned Departmental reports and related documentation related to quality management and performance improvement activities within the Center for Discovery system. Furthermore, it is the QI Specialist’s function to assist QI staff and members of the Quality Improvement Group relative to Quality Improvement projects, initiatives and related activities as assigned by the Director. Collecting and analyzing specialized data and preparing accurate reports in the areas of quality improvement to assure patient care standards for La Maestra Community Health Centers. It also requires excellent communication skills with clinical and non-clinical departments, and the ability to develop collateral tools, documents, sustainability data methods, presentations, etc.-that enables the success of the work.

Responsibilities

Quality Improvement Activities/Data Collection

1. Compiles data and assembles reports related to quality improvement activities as assigned.
2. Data collected for analysis on a monthly basis
3. Data is harvested from but not limited to the following sources:

• Pharmacy Reviews (through the Director/supervisor of Nursing)
• Incident Reports
• Satisfaction Surveys
• Customer Complaint
• Facility Reviews, which may include information relative to Infection Control, Chart Audits, Employee Evaluations, Condition of the Building, Grounds and Equipment
• Fire/Disaster Drills and emergency procedures

• Assists in planning and executing quality improvement efforts and activities for all La Maestra Clinics/Providers. Submits data, action plans, and all information requested on behalf of La Maestra.
• Maintaining and monitoring project plans, project schedules, work hours, budgets, and expenditures.
• Creating a project schedule with milestones and due dates. Documenting each phase of the project, summary reports and invoices pertaining to the projects.
• Documenting and following up on important actions and decisions from meetings.
• Assess project risks and issues and provide solutions where applicable and ensuring project deadlines are met.
• Providing administrative support as needed
• Work plans/project documents, including procedures, proposals, progress reports and presentations.
• PCMH/ QI audits and reporting
• Train new hires, on-going trainings, one on one training or group/ classroom training (in-person or virtual)

Joint Commission Accreditation and State Licensing Activities

1. Assists the QI Department with any NCQA, Joint Commission Accreditation and State licensing activities whenever requested.

 

General

1. Communicates with internal and external professionals, staff members, employees as required and in particular with members of the QI Group and the Directors of Operations of the different departments.
2. Participate in on-going department training, department meetings when required
3. Responsible to continually help update policy and procedure manual.
4. Works after hours when requested
5. Accepts all other duties as assigned
6. Keep all client, family and professional information confidential during and after time of employment.
7. Participates in any project as assigned by either the Director or Quality Improvement.

Additional Duties and Responsibilities

1. Attend staff meetings
2. Performs other duties as assigned.

 

Patient Centered Medical Home Essential Responsibilities (Principals)

• Collaborate with individual patients, their personal physicians, and when appropriate the patient’s family to ensure accessible, comprehensive, compassionate, and culturally competent care
• Facilitate care by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.
• Ensure all decisions respect patients’ wants, needs, and preferences and that patients have the education and support they require to make decisions and participate in their own care.
• Continually strive to attend to each patient “whole person,” in the context of the patient’s personal and medical history and life circumstances, rather than focusing on a particular disease, organ, or system

Job Requirements

Education:  Bachelor’s degree or Associates degree in related field preferred; High School Diploma required

Certification: Medical Assistant Certificate/Diploma preferred

Experience: 2-3 years of experience in related field.  

Verbal and Written Skills to perform the job:  Bilingual preferred. Familiarity with basic word processing, spreadsheet, and database applications.  Accurate keyboarding skills.

Technical knowledge and skills required to perform the job:  Excellent verbal, written and interpersonal communication skills and the demonstrated ability to work with diverse individuals and groups.  Demonstrate high levels of self-initiation and direction. Knowledge of communities we serve. Knowledge and experience working in medical settings and interacting collaboratively with medical teams.  Skill in analyzing situations and making timely decisions.

 

Physical and Mental Requirements:  Work involves sitting, talking, hearing, using hands to handle, feel or operate objects, tools, or controls, and reaching with hands and arms. The employee may be required to push, pull, lift, and/or carry up to 20 pounds. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

Quality Management

1. Display knowledge of normal signs of human development and ability to assess and provide age appropriate care.
2. Contribute to the success of the organization by participating in quality improvement activities

Customer Relations

1. Respond promptly and with caring actions to patients and employees.  Acknowledge psychosocial, spiritual and cultural beliefs and honor these beliefs.
2. Maintain professional working relationships with all levels of staff, clients and the public.
3. Be part of a team and cooperate in accomplishing department goals and objectives
4. Interacts and communicates in a manner to reflect an understanding of the patient’s age, culture, state of health, and level of comprehension

Safety

1. Maintain current knowledge of policies and procedures as they relate to safe work practices.
2. Follow all safety procedures and report unsafe conditions.
3. Use appropriate body mechanics to ensure an injury free environment.
4. Be familiar with location of nearest fire extinguisher and emergency exits.
5. Follow all infection control procedures including blood-borne pathogen protocols

HIPAA/Compliance

1. Maintain privacy of all patient, employee and volunteer information and access such information only on a need to know basis for business purposes.
2. Comply with all regulations regarding corporate integrity and security obligations. Report unethical, fraudulent or unlawful behavior or activity.

Work Environment

 

1. The noise level in the work environment is usually moderate

1. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

General Requirements

Pre-employment requirements include I-9 verification, physical examination, positive background and reference check results, completed employment application, new hire orientation attendance.

 

OSHA Compliance

1. Comply with all regulations and required schedules regarding OSHA training.

Employee Physical Compliance

1. Required physical to be performed annually.

 

Policies and Procedures Compliance

1. Responsible for following all La Maestra Family Clinic policies and procedures.

Meal Period Compliance (Non-exempt employees only.)

1. Punch out before 5 hours from the start of shift for meal periods.

Sexual Harassment Training (Management employees only.)

1. Comply with all regulations and required schedules regarding sexual harassment training.