KIC Quality Management/Safety Director Job Description
KETCHIKAN INDIAN COMMUNITY JOB DESCRIPTION
Position: / Quality Management/Safety Director / Reviewed by:Department: / Clinic / Supervisor / August 2005
Reports to: / Health Administrator / HR Director / August 2005
Status: / o Exempt / o Non-exempt / Approved by:
Full-Time, Permanent / General Manager
Indian Preference: In accordance with the Indian Preference Act of 1934, application for the position must include verification of Indian blood.
Purpose
Ketchikan Indian Community (KIC) job descriptions are a management tool to help organize duties and provide employees with the employer’s expectations with regard to a specific job classification. The duties listed are intended only as illustrations of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is a reasonable assignment for the position. This job description is not an employment agreement or contract. Management has the exclusive right to alter this job description at any time without notice.
Job Summary
Incumbent monitor and coordinate the Quality Management (QM) and Safety Programs of the health facility. Quality Management duties are to ensure compliance with Association Accreditation of Ambulatory Health Care (AAAHC) Accreditation Standards and all other local, state, and federal regulatory agency requirements. The Safety Director manages and oversees all Clinic safety programs in order to maintain a safe environment for patients, visitors, and personnel in cooperation with Clinic Administration.
Duties are carried out with considerable independence with general supervision of the Health Administrator.
Essential Quality Management Job Functions:
establishes and accomplishes QUALITY MANAGEMENT objectives by
Ø Chairing the Quality Management Committee;
Ø Participating in the Government Performance Results Act (GPRA) to ensure compliance with Health Families 2020 Guidelines and Indian Health Service;
Ø Collecting data related to established criteria in an on-going manner and periodically evaluated to identify acceptable or unacceptable trends or occurrences that affect patient outcomes.
PROVIDES QUALITY MANAGEMENT ACCREDITATION REQUIREMENTS BY
Ø Chairing the Quality Management Committee;
Ø Identifying, monitoring, and reporting QM Committee’s annual goals and objectives;
Ø Conducting patient satisfaction surveys;
Ø Managing and responding to patient comments;
Ø Assessing and providing QI training at all levels to ensure QI philosophy and practices;
Ø Communicating the QI/QM activities findings to staff and supervisor to close the QI Loop;
Ø Updating Quality Management Handbook bi-annually.
Essential Accreditation Job Functions
MONITORS ASSOCIATION OF ACCREDITATION FOR AMBULATORY HEALTH CARE (AAAHC) ACCREDITATION REQUIREMENTS BY
Ø Collecting quarterly committee reports and monitoring goals and objectives;
Ø Reporting status of committee goals and objectives to Health Administrator;
Ø Educating staff (upon hire and per annual training schedule) of his/her teamwork responsibilities to maintain accreditation standards;
Ø Scheduling preliminary AAAHC self-assessment meetings with appropriate director/committee chair;
Ø Completing self-assessment report and forwarding to Health Administrator and General Manager for completion schedule dates;
Ø Submitting AAAHC accreditation application;
Ø Scheduling and arranging mock AAAHC survey;
Ø Reporting mock survey results to Health Administrator and General Manager;
Ø Monitoring and reporting status of “punch list” accreditation deficiencies to supervisor;
Ø Scheduling and finalizing AAAHC accreditation survey date and agenda;
Ø Participating in survey visit;
Ø Reporting final survey results to supervisor.
Essential Safety Director Job Functions
MAINTAINS A SAFE AND HEALTHFUL ENVIRONMENT BY
Ø Identifying and anticipating concerns and hazards; developing and enforcing systems, policies and procedures;
Ø Surveying environmental, operational, and occupational conditions, rending opinions on new equipment and procedures, investigating violations, recommending preventive programs.
Ø Conducting scheduled/unscheduled safety inspections, reporting results, and advising directors;
Ø Educating staff (upon hire and per training schedule) to assure safe environment continuity;
Ø Submitting monthly reports.
MAINTAINS PROFESSIONAL AND TECHNICAL KNOWLEDGE BY
Ø Attending educational workshops;
Ø Reviewing professional publications;
Ø Establishing personal networks;
Ø Benchmarking state-of-the-art practices;
Ø Participating in professional societies.
CONTRIBUTES TO TEAM EFFORT BY
Ø Accomplishing related results as needed;
Ø Initiating and directing training programs and in-services for department employees;
Ø Evaluating the structure and team plan for continual improvement of the efficiency and effectiveness of the department;
Ø Perform other related duties as directed by supervisor.
KNOWLEDGE, SKILLS, AND ABILITIES
Ø Knowledge of Indian health care programs in a rural setting;
Ø Knowledge of accreditation or other applicable standards within health care, sufficient to achieve and maintain accreditation;
Ø Knowledge of NFPA and OSHA regulations relative to an ambulatory health care facility;
Ø Knowledge and ability to carry out the AAAHC accreditation standards;
Ø Knowledge and ability to carry out rules of Health Insurance Portability and Accountability Act (HIPAA), which protects patient and employee rights;
Ø Knowledge of office equipment and limited maintenance;
Ø Knowledge of word processing and spreadsheet computer application skills;
Ø Skill in developing a quality assurance program within an Indian health care setting
Ø Skill in writing as would be required for reports, plans, grants proposals, program justifications, etc.
Ø Ability to understand and adapt to the Indian and Alaska Native cultures throughout the region;
Ø Ability to read, analyze, and interpret the most complex documents;
Ø Ability to respond effectively to the most sensitive inquiries or complaints;
Ø Ability to make effective and persuasive speeches and presentation on controversial or complete topics both external/internal parties;
Ø Ability to communicate professionally over the telephone and in person in a positive and clear manner;
Ø Ability to communicate orally, and in writing to staff members from a variety of backgrounds - professionals, technicians, and clerical;
Ø Ability to manage simultaneously multiple tasks, including telephone, computer operations and in-person visits;
Ø Ability to be flexible in order to perform at the highest level as a team player;
Ø Ability to utilize maximum degree of professionalism and diplomacy with those who may be experiencing a high degree of stress both mentally and/or physically;
Ø Ability to maintain confidentiality of all Tribal operations and staff.
Physical Activities Include
Must be able to hear. Specific vision abilities include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus. Ability to use hands to finger, handle, or operate objects tools, or controls; reach with hands and arms; climb or balance; stoop, kneel, crouch; and taste or smell. Each of the listed activities also requires standing, sitting, walking, bending, and stooping, climbing on stools and ladders, and routinely lifting and carrying items and boxes up to forty (40) pounds.
Writing by hand and using a personal computer. Long hours in front of computer screen. Frequently required to work extended hours. Attending evening and lunch time meetings as requested by the General Manager. Traveling occasionally, using air and/or water transportation, to out-of-town meetings and functions.
WORKING ENVIRONMENT
The environment involves the usual risks and stress of an office environment within an ambulatory health care facility. The employee may be exposed to communicable diseases. Safety precautions for employees such as blood drawing for screening of various diseases such as hepatitis, required immunizations, etc. are necessary.
The employee is occasionally subject to verbal abuse, threats, and physical violence from angry, hostile, or disgruntled employees and/or family members. A high stress position due to complex issues and crises involving the operation of an ambulatory health care facility.
License(s)
Possess current valid State of Alaska driver's license with a record acceptable to KIC’s Insurance carrier.
EDUCATION & EXPERIENCE
High school diploma or equivalent required. Associate degree in business or public administration required with Bachelor’s degree preferred.
Minimum of five years quality management or safety experience in a health care organization, with demonstrated leadership. A minimum of two years of experience required for those with an associate degree in business or public administration. A minimum of ten years experience with quality improvement activity in health care required for candidates without a college degree.
Any combination of related education and/or related experience will be considered if the candidate posses the demonstrated ability.
Individual must be able to pass a pre-hire drug screen and
Full background investigation
Native Preference in accordance to P.L. 93-638
Applications to: Ketchikan Indian Community
Attn: HR
2960 Tongass Avenue
Ketchikan, AK 99901
Fax: 907-228-5245
Closing date: Open Until Filled
Job Descriptions\Clinic Administration Page 4 of 4 Adopted: 1997
Revised: 00, 03, 05, 09, 11