POSITION TITLE: Manager, Quality and Performance Improvement
REPORTS TO: CQMO
REVIEWED/REVISED: April 2019
Manet Community Health Center is a federally qualified community health center that is fully licensed by the Department of Public Health and accredited by The Joint Commission. Manet serves all patients regardless of their ability to pay or health insurance status and is especially committed to providing services for the medically underserved and ensuring that patients have access to the highest quality patient care. Manet has five locations, three in Quincy, one in Hull and one in Taunton, Massachusetts.
General Definition and Scope of Job
Under supervision of the Sr. Director of Operations and with responsibility to the Chief Quality Officer, the Manager of Quality and Performance Improvement is responsible for supporting the Quality and Performance Improvement Plan activities that ensures Manet’s consistent performance of best practice, leading to a high level of patient satisfaction, effective, efficient safe and high quality care that maintains compliance with regulatory requirements and accreditation standards. In this hands-on-role, the quality manager will implement and manage clinical quality measurement and improvement projects; assist in the development of performance strategies and their implementation, and develop techniques for evaluating the efficacy of interventions. He/she will assist in identifying problematic areas in the delivery of care and facilitate Performance Improvement groups to improve those areas and provide analyze and share data after improvements are implemented.
- Under the direction of and in partnership with the Sr. Director Operations & Chief Quality Officer, maintain and monitors the implementation of the Quality & Performance Improvement Plan and all day-to-day activities related to Manet’s programs and services. Identifies inefficiencies on areas of improvement and quality and works across all levels of the organization to implement corrective actions;
- Participates in the design and implementation of the annual Quality &Performance Improvement Plan and working agenda. Provides project management and support to operational, quality, safety and/or performance improvement teams;
- Applies, teaches and skillfully uses techniques for system design, re-engineering, quality improvement, outcomes measurement and statistical analysis to advance the Quality & Performance Improvement Plan;
- Oversees the process of abstracting data and collating data from various administrative and clinical studies, and analyzes such data via current statistical reporting methods (e.g. health outcomes management). Assures that data and proposed resolutions are documented and reported within the organization and to the Performance Improvement Committee and the CMO. Recommends new or revised policies, procedures and practices; based upon results. Prepares quarterly, semi-annual and annual reports for leadership, governance and regulators;
- Partners with the performance improvement teams in collaboration with clinical and operational team leaders, senior clinicians and administrators regarding proper application and implementation of performance improvement measures, as identified during performance management activity.
- Collect and monitor clinical quality measurements’ and report specific results/outliers to the leadership.
- Supervises the clinical care coordinator who provides daily care coordination, case management, coaching, consultation and intervention to patients with one or more chronic diseases. Responsible for identifying said population via provider/clinic referral, utilization management referral, disease registry reporting mechanisms and patient self-referral.
- Maintains effective, collaborative working relationships with the Chief Quality Officer, CMO, Nursing Director and Sr. Director Operations to ensure achievement of health outcome measures and coordination of efforts, including:
- Collecting and analyzing data on all Health Care Plan, P4P and incentive measures;
- Providing a monthly quality measurement report for leadership; and,
- Produce as requested a monthly dashboard on chronic disease care measures, preventive health and clinical operational measures to leadership.
- Under leadership direction, organizes and creating all necessary training modules regarding performance improvement for all levels of the organization. Collaborates with the CQO, CMO, Nursing Director and Sr. Director Operations in such efforts, particularly in regard to quality, efficiency and patient safety.
- Serves as resource and coordinates the peer review activity for the providers as well as performance management matters and continuing education related to same.
Supports several committees and programs, as follows:
- CAC – Provides staff resource for the Patient Care Assessment Committee (meets quarterly). Reports on efforts at process re-design, performance management, analysis and suggested improvements. Serves as the senior resource to all departments, leadership and governance in continuously identifying process improvement opportunities.
- Operations – Attends meetings as needed.
- HRSA – Participates in respective areas of responsibility related to the Section 330(e) Health Care Plan and Business Plan.
- Utilization Data Review: Participate in analyzing data for outcomes to improve performance and responsible to collect and collate data and share as appropriate in leadership meetings.
- Participate in analyzing data through the year for performance and quality improvement. Must present collated annual data at year end.
- PFAC – is liaison between Manet and the patient, helping to facilitate the agenda.
Education, Skills and Experience Requirements:
- RN or LPN required
- Requires a Bachelor’s degree, in nursing and/or equivalent degree required; Master’s degree in relevant field preferred, (e.g. MHA, MPH, MPA, and/or MBA)
- Must have previous clinical and quality data experience.
- Requires a minimum of 3 to 5 years’ experience successfully implementing performance improvement and quality programs in a complex health care environment, FQHC preferred;
- Working knowledge of a variety of rigorous process improvement and quality outcome measurement methodologies, such as Lean, Change Management, Value Stream Mapping, Rapid Cycle Testing, PDSA, FMEA, 330 Health Care and Business Plans, Healthy People 2020, HEDIS, P4P;
- Working knowledge of regional health disparities and social determinants of health;
- Working knowledge of the Integrated Care Model and its use in performance improvement
- Oversees and ensures Manet has policies and procedures necessary for maintenance of continued PCMH recognition status and HPC PRIME certification;
- Effective computer software skills including QA/PI management-related applications and database management. Computer literacy and the ability to perform sophisticated statistical analysis.
- Ability to write reports, business correspondence, and procedure manuals.
- Ability to effectively present information and respond to questions from groups of managers, clients, customers and the general public.
- Multi-tasking ability required. Comprehensive organization skills required.
- Evidence of proven leadership, meeting facilitation, project management and time management skills;
Other Skills and Abilities Required:
- Understand clinical practice patterns. Ability to discuss clinical practices with physicians, quality improvement professionals, health plan medical directors, and federal and state government officials.
- Superior communication skills (verbal and written) with the ability to communicate quality improvement data and methods to Manet staff with varying technical and clinical backgrounds.
- Familiarity with quality improvement principles and techniques, including the research and intervention design.
- Ability to work independently with minimal supervision and as part of a team.
- Must have flexibility of work hours and ability to travel when needed.
Required Certifications and Licenses
CPHQ certification or similar certification desired.
- Works in well-lit environment with comfortable surroundings.
- Stressful at times due to competing demands, including attention to multiple patients and staff.
- Will comply with all applicable laws, and will cooperate with the Manet Community Health Center compliance program rules and regulations
May be required to work at multiple locations
Please send resumes to: email@example.com