Quality Improvement and Accreditation Director

This position is a covered position as defined in the Coquille Indian Tribe Chapter 185 Child Protection Ordinance.

SUMMARY OF MAJOR FUNCTIONS

Under the direct supervision of the Chief Operating Officer, the Quality Improvement and Accreditation Director is responsible for leading, developing, and implementing comprehensive quality improvement, patient safety, and risk management programs. Provides strategic leadership for organizational performance improvement through the development of clinical benchmarking systems, enterprise-wide quality reporting, population health measurement, and cross-departmental improvement initiatives that support integrated, team-based care and advance the health and wellness of Tribal members and communities.

Essential Duties and Responsibilities

1. Provide leadership and oversight for quality improvement, quality assurance, patient safety, and risk management initiatives that improve outcomes for staff, patients, clients, and the Health and Wellness Division. Develop and oversee processes for monitoring and improving quality of care.
2. Supervise the Quality Improvement Manager and other assigned staff, providing direction, coaching, performance management, and professional development.
3. Design, implement, and evaluate a comprehensive clinical quality measurement and benchmarking program. Collaborate with leadership and clinical teams to establish meaningful quality metrics, monitor performance against internal and external benchmarks, and identify opportunities for improvement.
4. Lead the collection, analysis, interpretation, and presentation of clinical and operational performance data to support strategic decision-making, operational efficiency, regulatory compliance, accreditation, and organizational accountability.
5. Develop and oversee quality dashboards and scorecards that communicate performance outcomes, benchmark comparisons, trends, and progress toward strategic and operational goals.
6. Lead organization-wide performance improvement initiatives using evidence-based methodologies, including PDSA and root cause analysis. Develop corrective action plans and monitor the effectiveness and sustainability of interventions. Partner with medical, dental, behavioral health, pharmacy, rehabilitation, nutrition, community/public health, and other leaders to develop quality improvement and community health initiatives that advance team-based, patient-centered, culturally responsive care and improve health outcomes.
7. Collaborate with executive leadership to establish annual quality priorities, organizational performance targets, and department-specific goals aligned with Health and Wellness Division strategic objectives and Tribal health priorities.

1. Monitor healthcare disparities, health equity measures, access, utilization, and population health outcomes. Partner with leadership to develop strategies that improve outcomes while honoring Tribal values, traditions, and culturally informed practices.
2. Collaborate with information technology, electronic health record teams, and department leaders to improve data integrity, reporting capabilities, and use of clinical information systems to support quality improvement and population health management.
3. Promote a culture of continuous quality improvement by providing education, coaching, and technical assistance to leaders, providers, supervisors, and staff regarding quality improvement principles, performance measurement, patient safety, and regulatory requirements.
4. Oversee and support the incident review and complaint process for KWC and use findings and trend data to identify opportunities for ongoing quality improvement and risk reduction.
5. Oversee and support preparation for regulatory and accreditation reviews, including AAAHC, CARF, and other applicable oversight organizations.
6. Educate and assist department supervisors in maintaining policies and procedures that meet regulatory and organizational requirements. Ensure policies and procedures are reviewed regularly and that operational practices are consistent with approved policies.
7. Lead Quality Improvement Committee meetings or support an assigned designee and ensure follow-through on committee recommendations and action items.
8. Coordinate complex, system-wide projects involving multiple departments, programs, and functional areas, ensuring effective communication, implementation, and follow-through.
9. Perform other duties as assigned.

The above statements reflect the general duties considered necessary to describe the principal functions of the job as identified and shall not be considered as a detailed description of all the work requirements that may be inherent in the job.

PHYSICAL REQUIREMENTS          

Requires the ability to communicate orally, repetitive movement of the wrists, hands and/or fingers, often requires walking, standing, sitting for extended periods of time, raising or lowering objects, stooping and occasionally requires lifting up to 50 pounds. Work is generally performed in an office setting. Will often be required to travel by automobile, commercial or private carrier. Local travel is frequently required, statewide and national travel is occasionally required. The individual must perform the essential duties and responsibilities with or without reasonable accommodation efficiently and accurately without causing a significant safety threat to self or others. 

REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES

Individuals must possess the following knowledge, skills and abilities or be able to explain and demonstrate that they can perform the essential functions of the job, with or without reasonable accommodation, using some other combination of skills and abilities.

1. Excellent verbal and written communication skills with strengths in team building, and cooperative problem solving.
2. Ability to consistently convey a pleasant and helpful attitude by using excellent interpersonal and communication skills to control sometimes stressful and emotional situations.
3. Ability to foster an inclusive workplace where diversity and individual differences are valued and leveraged to achieve the vision and mission of the Coquille Indian Tribe.
4. Working knowledge of paperless record retention system.
5. Develops the ability of others to perform and contribute to the organization by providing ongoing feedback and by providing opportunities to learn through formal and informal methods.
6. Ability to make decisions independently in accordance with established policy and procedures.
7. Proficiency with Microsoft 365 and related Microsoft technologies, including Word, Excel, Outlook, Teams, SharePoint, and other digital tools necessary to prepare correspondence, documents, spreadsheets, reports, and presentations.
8. Self-driven and motivated to increase efficiency and performance.
9. Proficiency in applying basic mathematical and statistical concepts to perform accurate calculations and support day-to-day job responsibilities.
10. Ability to work cooperatively with   other departments to accomplish assigned tasks; ability to develop good working relationships with other departments in the organization.
11. Must have acute attention to detail and demonstrate effectiveness in managing multiple work assignments simultaneously, often under strict deadlines.
12. Ability to work independently, demonstrate initiative and take ownership of all projects and assignments.
13. Ability to exercise excellent organization, time management, analytical and problem-solving skills.

REQUIRED Qualifications

1. Bachelor’s degree in nursing or other health related field required.
2. Certified Professional in Healthcare Quality (CPHQ) or eligibility to obtain within 6 months of employment required.
3. Minimum five (5) years of experience in a clinical healthcare setting required.
4. Minimum five (5) years of experience in health care quality improvement and risk management required.
5. Minimum five (5) years of supervisory experience required.
6. Extensive knowledge of Microsoft Office, desktop publishing techniques and web publication software products required.
7. Must have proven track record as a team player.
8. Must possess a current, valid driver’s license and maintain an insurable driving record as determined by the Tribe’s insurance carrier.

PREFERRED Qualifications

1. Preference given for work experience in Tribal health care setting.
2. Technical report writing skills preferred.
3. Knowledge of Indian Health Service and Bureau of Indian Affairs programs preferred.