Summary: Responsible for implementation of activities and procedures to ensure adherence to PHC's policies and procedures. Ability to review and analyze data and agency observation to assist with improvement of quality processes. Monitoring activities are ongoing daily and require written reports of findings and recommendations for improvement. Work with health center employees on identification of opportunities for improvement, implementation of improvement action plans, follow-up evaluations and continuous monitoring for adherence to PHC policies and procedures. Perform job duties under the direction of Director of Quality and Compliance. Essential Duties and Responsibilities Include the following. . . Monitors and collects data related to performance improvement plan. Performs data net for personal computer. Provides monthly statistical reports on compliance. Participate in the health center's performance improvement, safety, infection prevention, compliance, and emergency response plans. Assist in the assessment and solution of identified performance improvement problems; participate with implementation and ongoing monitoring for compliance to PHC policies and procedures. Assist with implementation of new and/or revised policies. Assist with policy writing for agency procedures. Assist with staff training/presentations related to improvement activities and program requirements. Maintain required department records, reports, and files necessary to ensure proper documentation and follow up of compliance information. Attends meetings as requested. Function within the legal and ethical parameters of your profession, as a member of the interdisciplinary treatment tearn and according to the policies of BJK People's Health Centers. Participate in outreach activities; volunteer participation in at least two health center-sponsored comtnunity events for a minimum of four hours each. Review and reporting related to department quality control logbooks assessing compliance levels. Monitors equipment checks assessing compliance with service maintenance and safety checks. Monitors emergency kit/cart (oxygen, supply medication checklist) for compliance to emergency policies and procedures. Conducts and schedules random patient satisfaction surveys (i.e., written, phone, interview) and provides written reports of findings. Provide continuous monitoring and reporting of patient/visitor complaints/suggestions and make recommendations to performance improvement committee. Performs frequent monitoring and observation of department (registration/appointments, nursing, dental, WIC, social service, lab, radiology, Medical records, and housekeeping) activities ensuring compliance with health center policies (i.e., distribution of pt plan, HIPAA information, and protection of PHI). Monitors health center programs to ensure program's existence continues and current program data is collected and reported. Assists with implementation and achievement of the health center's annual performance improvement goals and activities. Monitors and reports compliance findings related to AAAHC requirements. Monitors and reports compliance findings related to Patient Centered Medical Home and NCQA requirements. Provider Quality and Infection Control Department orientation as requested. Other duties as assigned. Supervisory Responsibilities: This job has no supervisory responsibilities. Competency: To perform the job successfully, an individual should demonstrate the following competencies: Analytical - Collects and researches data. Design - Uses feedback to modify designs; Demonstrates attention to detail. Problem Solving - Identifies and resolves problems in a timely manner, Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group and individual problem solving situations; Uses reason even when dealing with emotional topics. Project Management - Communicates changes and progress. Technical Skills - Assesses own strengths and weaknesses; Pursues training and development opportunities; Strives to continuously build knowledge and skills; Shares expertise with others. Customer Service - Manages difficult or emotional customer situations; Responds promptly to customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance; Meets commitments. Interpersonal Skills - Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others' ideas and tries new things. Oral Communication - Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; Responds welt 10 questions; Participate in meetings. Written Communication - Writes clearly and informatively; edits work for spelling and gratnrnar; Varies writing style to Ineet needs; Able to read and interpret written information. Teamwork - Balances team and individual responsibilities; Exhibits objectivity and openness to others' views; Gives and welcomes feedback; Contributes to building a positive team spirit; Puts success of team above own interests; Supports everyone's efforts to succeed; Embodies a team-based approach to patient care. Visionary Leadership - Inspires respect and trust. Leadership - Exhibits confidence in self and others; Inspires and motivates others to perform well; Accepts feedback from others; Gives appropriate recognition to others. Diversity Demonstrates knowledge of EEO policy; Shows respect and sensitivity for cultural differences; educates others on the value of diversity; promotes a harassment-free environment; Builds a diverse workforce. Ethics - Treats people with respect; Keeps commitments; inspires the trust of others; Works with integrity and ethically; Upholds organizational values; maintains confidentiality of information received. Organizational Support - Follows policies and procedures; Completes administrative tasks correctly and on time; supports organization's goats and values; Supports affirmative action and respects diversity. Judgment - Displays willingness to make decisions; Exhibits sound and accurate judgment; Supports and explains reasoning for decisions; Includes appropriate people in decision-making process; Makes timely decisions. Motivation - Sets and achieves challenging goals; Measures self against standard of excellence. Planning/Organizing - Uses time efficiently; sets goals and objectives. Professionalism - Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments. Quality - Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance; Monitors and proofs own work to ensure quality. Quantity - Completes work in a timely manner. Performs chart audits/reviews as expected. Safety and Security - Observes safety and security procedures; Reports potentially unsafe conditions; Uses equipment and materials properly. Adaptability - Adapts to changes in the work environment; Changes approach or method to best fit the situation; Able to deal with frequent change, delays, or unexpected events. Attendance/Punctuality - Is consistently at work and on time; Ensures work responsibilities are covered when absent; Arrives at meetings and appointments on time. Dependability - Follows instructions, responds to management direction; Takes responsibility for own actions; Keeps commitments; Commits to long hours of work when necessary' to reach goals. Completes tasks on time or notifies appropriate person with an alternate plan, Initiative - Volunteers readily; Looks for and takes advantage of opportunities; Asks for and offers help when needed. Innovation - Displays original thinking and creativity; Generates suggestions for improving work; Presents ideas and information in a manner that gets others' attention. Qualifications: Requires bachelor's degree in nursing (BSN) or Advanced Degree in primary health, health administration or related health field. Experience in public health environment and excellent communication skills. Education and/or Experience: Bachelor's degree (B. A.) fronl four-year College or university; or one to two years related experience and/or training; or equivalent combination of education and experience. Language Skills: Ability to read and interpret documents such as safely rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability 10 speak effectively before groups of cust01ners or employees of an organization. Mathematical Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs. Reasoning Ability: Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations. Computer Skills: To perform this job successfully, an individual should have knowledge of Database software and Word Processing software. Requires ability to compile reports; ability to use access, excel and other programs to present reports/graphs. Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is frequently required to sit and talk or hear. "Ille employee is frequently required to stand and walk. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include ability to adjust focus. To perform the job requirements, this position requires travel to all agency sites/locations and may require travel for required training. Work Environment: "Ihe work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate. Age Specific Requirements: Applicable I acknowledge that I have read and fully understand the above job description and agree to abide by its content. I understand that failure to satisfactorily perform the assigned duties may result in disciplinary action and/or termination.