An employee working as Chief Quality Officer for Shasta Cascade Health Centers (SCHC) is responsible for the overall quality assurance, quality improvement, risk management, and patient safety activities of SCHC. The Chief Quality Officer works closely with SCHC’s Leadership and Management Teams.
Co-chairs SCHC’s Quality Assurance/Performance Improvement (QAPI) Committee; coordinates the activities of the QAPI Committee; creates and maintains QAPI meeting agendas and minutes.
Maintains and updates the Annual Quality Assurance/Improvement and Risk Management Calendar. Coordinates all activities to ensure completion on schedule.
Coordinates an Annual Risk Assessment with appropriate staff and prioritizes identified risk mitigation activities.
Writes and presents the Annual QA/QI Report and Annual Risk Management Report to the QAPI Committee, key leadership staff, and the Board of Directors for submission with the annual Federal Tort Claims Act (FTCA) re-deeming application.
Reports quarterly to the QAPI Committee, key leadership, and the governing Board regarding quality improvement/assurance and risk management activities and issues. Reports include but are not limited to audits of staff performance in high-risk areas (e.g., referral tracking, tracking lab/imaging orders, scheduling follow-up visits for patients discharged from the hospital and emergency room, clinical incident trends, and patient complaints), and results of patient satisfaction surveys.
Reviews and updates the Health Center’s QA/QI Plan and Risk Management Plan as needed. Submits Plans to the governing Board for approval.
Monitors Health Center performance on quality of care indicators outlined by Partnership HealthPlan Quality Improvement Program and the Health Resources and Services Administration (HRSA).
Collaborates with the Director of Clinical Operations (DCO) to support medical assistants and nurses for improving Uniform Data System (UDS) and the Health Effectiveness Data and Information Set (HEDIS) metrics.
Collaborates with the Chief Medical Officer (CMO) to work with individual providers on improving clinical indicator quality scores and sharing their quality report cards.
Works with CMO and DCO to initiate Plan-Do-Study-Act (PDSA) projects for quality indicator performance improvement as needed.
Assists the CMO with SCHC’s Peer Review Program.
Extracts and reviews data from the electronic health record (EHR) used to monitor staff performance, develop performance improvement plans, and assess progress towards goals. Facilitates “clean up” of data to ensure accuracy of quality indicator reports (e.g., attaching results to orders for UDS credit). Utilizes trigger reports (e.g., high-risk pregnancies, unlocked encounters) to audit medical records for “red flags.”
Reviews and follows up on clinical incident reports, patient complaints, and patient satisfaction surveys/comment cards to identify issues affecting risk, quality, and safety.
Coordinates root cause analyses with appropriate staff on sentinel events.
Assists the Chief Executive Officer (CEO) in the reporting and management of claims and potentially compensable events according to FTCA procedures.
Provides direction, training, and development involving all aspects of quality improvement, patient safety, and risk management.
Participates in onboarding of new employees as appropriate to review patient safety, quality, and risk management expectations. Serves as point of contact for Occupational Safety and Health (OSHA) mandated trainings (e.g., Blood Borne Pathogens (BBP) and Exposure Control Plan (ECP)). Conducts OSHA trainings with Director of Clinical Operations, coordinates and ensures the review BBP and ECP annually.
Facilitates the inclusion of quality, risk, and safety learning modules for onboarding and annual training in Compliatric, SCHC’s learning management system.
Promotes a culture of safety among staff, assesses staff perception of the current culture of safety, and implements educational programs aimed at mitigating risks, enhancing safety, and improving quality.
Implements quality, risk, and safety programs that fulfill regulatory, legal, and accreditation requirements.
Prioritizes SCHC’s risk management, patient safety, and quality improvement projects and initiatives according to strategic priorities.
Serves as a liaison between SCHC’s clinical sites and departments to facilitate quality performance and risk management functions; coordinates and collaborates with departments in establishing and carrying out responsibilities.
Conducts walking rounds/inspections to assess for risks and invite feedback from staff regarding safety, quality, and risk concerns.
Collaborates with clinical operations staff and medical staff leadership on special projects relating to improved operations, processes, and procedures.
Serves as the SCHC’s Health Insurance Portability and Accountability Act of 1996 (HIPAA) Security Officer.
Participates in Leadership and Clinical Operations Team meetings, Provider Meetings, QAPI Committee meetings, and Executive QAPI Committee Meetings. Attends monthly governing Board meetings. Attends governing Board committee meetings as needed.
Develops, reviews, and recommends SCHC’s policies and procedures.
Develops recommendations and presents matters requiring a decision to the Chief Executive Officer, with financial decisions directed to the Chief Financial Officer.
Participates in monthly Health Alliance of Northern California (HANC) Quality Improvement calls and California Primary Care Association (CPCA) State-wide Quality Improvement and Compliance Officer Peer Group calls.
Prepares the annual HRSA FTCA re-deeming application.
Completes quality improvement section of the HRSA Service Area Competition (SAC) grant.
Participates in annual HRSA Uniform Data Set (UDS) reporting and oversees submission of data for Partnership HealthPlan’s Quality Improvement Program (QIP) reporting.
Performs other necessary duties as required by the Chief Executive Officer and Chief Medical Officer.
Program Enhancement Goals
Further develop SCHC’s Risk Management Program, including obstetrics services.
Facilitate achievement of Patient Centered Health Center (PCMH) designation.
All SCHC employees are expected to:
Work as a team player to accomplish SCHC’s mission, vision, values, and goals.
Maintain operations by following SCHC’s policies and procedures, and report perceived need(s) for changes.
Provide the highest level of service to clients.
Maintain confidentiality by following all applicable HIPAA regulations.
Respect SCHC’s equipment used to perform job tasks.
This position supervises the Quality Improvement Coordinator(s) and insures those assigned to working on quality improvement projects are held accountable and communicate with the rest of the organization as needed.
This job operates in professional office and medical clinic environments. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets, and fax machines.
Travel is required to carry out essential job functions and training. SCHC operates health centers in three south Siskiyou communities (McCloud, Dunsmuir, and Mount Shasta). Travel may occasionally be required for personal professional growth training purposes. If a personal vehicle is used for specified job-related errands or travel to/from training events outside of southern Siskiyou County, mileage will be reimbursed as specified in the Employee Handbook.
Education, Experience, Certifications, Licenses and Registrations:
A degree from an accredited educational facility such as: Registered Nurse (RN), Bachelor’s Degree, Master’s Degree, or Doctorate in a health care, business, or management field with three to five years’ experience in health care management preferred.
Certification in Risk Management, Quality and/or Patient Safety required or certification within 2-3 years of hire. One of the following would be an acceptable certification:
Certified Professional in Patient Safety (CPPS)
American Society of Healthcare Risk Management (ASHRM)
Certified Professional in Healthcare Risk Management (CPHRM)
Certified Professional in Healthcare Quality (CPHQ)
One to two years of utilization review, risk management, patient safety, and quality assurance/performance improvement experience. Experience at a Federally Qualified Health Center (FQHC) is preferred.
Thorough knowledge of medical record requirements.
Basic management skills related to healthcare organizations.
Demonstrated leadership skills, knowledge of quality improvement, risk management, and patient safety principles and practices including plan-do-study-act (PDSA), root cause analysis, and failure mode effects analysis (FMEA).
Demonstrated knowledge of external regulatory agencies such as HRSA and Center for Medicare & Medicaid Services (CMS).
Experience implementing PCMH and facilitating and coordinating healthcare improvement projects at a system level.
Demonstrated ability to utilize data to analyze performance, develop and implement improvement plans and processes, analyze outcomes, and reformulate improvement processes when goals are not yet achieved.
Demonstrated high degree of creative problem solving.
Passing a background check, and passing credentialing and privileging.
Skills and Competencies:
Ability to effectively communicate verbally and in writing with providers, clinical staff, and administrative staff. Ability to manage people and groups effectively. Ability to work independently as well as work as in a team. Ability to plan, organize, and use time efficiently. Exhibit ethical conduct, flexibility, initiative, ability to multi-task, highly organized, and detail orientated. Customer services skills, sensitivity to client needs, upholds strict confidentially requirements. Familiarity with computer processes, including Microsoft Word, Excel, and PowerPoint. Familiarity with or ability to learn electronic health records (e.g., eClinicalWorks) and data extraction/management programs (e.g., BridgeIT, eBO reports).
The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing job duties, the employee is regularly required to talk and hear. The employee is frequently required to stand, walk, reach with hands and arms, and use hands and fingers.
Ability to communicate effectively in person, by phone and by email.
Ability to visually interpret printed materials, memos, and other needed paperwork.
Ability to lift or move objects weighing up to 25 pounds.
Ability to sit for long periods of time.
Ability to travel between SCHC’s health center locations.
NOTE: Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities of this job at any time.
Internal Number: Quality Manager
About McCloud Healthcare Clinic, Inc.
Shasta Cascade Health Centers is a rural Federally Qualified Health Center consisting of 3 health centers in Northern California. Our small Health Center Group is nestled at the base of beautiful Mount Shasta and offers a family and community feel. Our interests are in treating the whole person by offering a mixture of medical, dental, chiropractic and behavioral health services.
Shasta Cascade Health Centers is a comprehensive primary healthcare practice dedicated to building a healthy community and improving the individual health, well-being, and quality of life for everyone.
For more information, please visit our website: