Reporting to the Executive Director, the Chief Quality Officer is responsible for developing and implementing a comprehensive compliance and performance improvement (CPI) program. The primary goal is to foster clinical and operational excellence, promote innovation, enhance efficiency, and drive standardization by utilizing best practices and an evidence-based approach. The Chief Quality Officer ensures compliance with all applicable laws and policies while encouraging continuous performance improvement.

In alignment with community health center requirements, the Chief Quality Officer creates and implements an annual CPI plan, conducts thorough reviews, generates detailed reports, and provides recommendations on policy, procedure, and training. Additionally, the Chief Quality Officer addresses compliance-related complaints, conducts investigations, and recommends appropriate actions based on the findings. This role involves close collaboration with all department leaders and key program managers to achieve organizational goals.

Responsibilities:

The Chief Quality Officer is responsible for developing guidelines and systems for the center's CPI Program, which must be approved by the Executive Director and Board. They periodically recommend updates to these guidelines and systems. The Chief Quality Officer also creates a detailed implementation plan for the CPI Program, which includes routine and random internal reviews, special investigations, and necessary reports. This plan encompasses reviews of all center activities, some of which are assigned to and conducted by the Chief Quality Officer.

In coordination with department heads, the Chief Quality Officer ensures that all internal audits are thorough enough to prevent and detect misconduct or inappropriate processes. They review patient and staff complaints promptly and effectively, ensuring that issues are investigated and resolved appropriately. The Chief Quality Officer conducts or oversees investigations into any allegations of misconduct or deviations from the center's Code of Conduct or policies and procedures, ensuring that the rights of both good-faith reporters and alleged violators are protected in accordance with the law.

They secure legal counsel through the Executive Director for complaints and investigations to protect the center's liability and comply with all reporting and other requirements. The Chief Quality Officer reports to the CPI Committee on audit and review summaries, recommending changes to measures and monitors to prevent misconduct and errors, and to implement performance improvement measures as needed.

Additionally, they evaluate the CPI Program and report to the Executive Director on its implementation, operations, and activities, making recommendations to enhance efficiency, performance improvement, quality of services, and reduce vulnerability to fraud, waste, and abuse. The Chief Quality Officer fosters a corporate culture that encourages the Board, leadership, staff, and independent contractors to report suspected fraud or misconduct without fear of retaliation. They also perform other related duties as assigned by the Executive Director. 

 Quality and Performance Improvement Duties:

• Coordinate, manage, and report on core measures, including but not limited to

VBC/ACO/UDS/PCMH measures.

• Design processes for new initiatives and services, focusing on better healthcare value and

quality, including clinical outcomes, patient experience, patient safety, costs, revenue,

productivity, efficiency, employee and physician satisfaction, and process reliability.

• Use data-driven strategies to improve patient outcomes, applying insights from quality

measure benchmarking to identify best practices in care.

• Facilitate alignment between improvement initiatives and the organization's strategic

plan, ensuring that behavior is standardized through both structure and process.

• Develop dashboards and scorecards incorporating metrics tailored to strategic or

operational goals.

• Communicate the impact of quality initiatives on federal/state payment/reimbursement

programs.

• Evaluate voluntary external standards to advise the organization on whether these

advance or impede the achievement of strategic goals.

• Ensure that processes are created to address gaps identified.

• Apply root cause analysis (RCA), FMEA, surveillance activities, and risk assessments to

identify and evaluate patient safety risks.

• Utilize findings from RCA, gap analysis, surveys, and audits to design appropriate

interventions across both containment actions and permanent corrective actions.

• Provide leadership and guidance in the development and implementation of the CPI

program that involves all departments and services.

• Intervene when necessary, involving senior leadership, to hold owners accountable for

actions and established deadlines.

• Oversee the coordination, submission, and monitoring of corrective action plans

associated with accreditation and/or certification of service lines.

• Ensure that the electronic document management system is maintained in alignment with

best practices concerning document control.

• Create a culture of passion and commitment for exemplary patient experience, working

closely with Patient Experience Supervisors to ensure patient perception of quality

initiatives are aligned.

• Collaborate with Frontera leaders to achieve goals exceeding national benchmarks.

• Analyze existing operational processes and workflows to identify inefficiencies,

bottlenecks, and areas for improvement.

• Implement Lean methodologies to improve process efficiency, reduce waste, and increase

quality.

• Collaborate with cross-functional teams to develop and implement effective solutions to

operational challenges.

• Lead continuous improvement projects, ensuring successful implementation and

adherence to timelines and budgets.

• Monitor the progress of improvement projects and report on results, adjusting strategies

as needed.

• Collect and analyze data on key performance indicators (KPIs) to assess process

performance and identify areas for improvement.

• Prepare detailed reports on process improvements and their impact on productivity, cost

savings, and quality.

• Provide training and coaching to staff on Lean principles, process improvements, and

best practices.

• Foster a culture of continuous improvement by encouraging and supporting employee

involvement in process enhancement initiatives.

• Develop and maintain a Quality Manual to include procedures, work instructions, and

forms to ensure consistency across the organization.

• Ensure that improvements are documented and shared with relevant teams for adoption.

• Work closely with other departments to align improvement efforts with overall business

goals.

• Facilitate collaboration between teams to ensure that process improvements are integrated

smoothly into day-to-day operations.

• Focus on identifying opportunities to reduce costs, improve resource utilization, and

enhance the sustainability of operations.

• Continuously monitor and evaluate processes to ensure long-term success and

sustainability of improvements.

• Lead continuous improvement efforts (e.g., mindsets, practices, and culture), working

with staff and leadership to develop, implement, and sustain a CPI program based upon

Lean principles that support meeting performance targets and financial goals.

• Leverage data and observational analysis to identify improvement opportunities.

• Lead cost-savings and value-creation projects from ideation and chartering through

successful completion and sustainment.

• Involvement in the formulation of long-term improvement strategies to deliver annual

business plans.

Compliance and Safety Duties:

• Develop, implement, and oversee Frontera’s Compliance Program as part of the CPI plan.

• Ensure compliance with the Federal Tort Claims Act (FTCA) requirements, which

provide liability protection for health centers and their providers, deeming them as Public

Health Service employees.

• Ensure that all clinical providers are properly credentialed and privileged

according to FTCA guidelines. Streamline the privileging and credentialing

processes in collaboration with HR to ensure clarity and efficiency.

• Implement risk management training and tracking tools to maintain FTCA

compliance.

• Handle claims and lawsuits in accordance with FTCA policies.

• Ensure adherence to the Health Resources and Services Administration (HRSA) Health

Center Compliance Manual, which provides guidelines for health center program

requirements, including quality improvement/assurance and FTCA deeming

requirements.

• Ensure compliance with the National Committee for Quality Assurance (NCQA) PatientCentered Medical Home (PCMH) standards.

• Achieve and maintain NCQA PCMH recognition by aligning health center

practices with NCQA standards.

• Implement policies and procedures for care coordination, patient education, and

self-management.

• Utilize NCQA standardized measures for quality improvement.

• Ensure compliance with the CMS Emergency Preparedness Rule.

• Implement and oversee the Risk Program.

• Ensure Human Resources Manager is completing compliance-related items in accordance

with state and federal regulations (e.g., OIG exclusion list, E-Verify).

• Support the peer review process, including committee coordination and process

improvement initiatives.

• Maintain up-to-date expertise on federal, state, and local regulations, including HRSA

operational guidelines.

• Act as the organization’s HIPAA Privacy Officer, ensuring compliance with privacy

regulations.

• Monitor occupational safety and ensure OSHA compliance.

• Deliver health and safety training and maintain emergency preparedness.

• Promote a safe workplace by advising on safety measures, conducting risk assessments,

and enforcing preventative measures.

• Investigate incidents to improve overall safety and ensure compliance with occupational

health and safety (OHS) guidelines.

• Provide training on safety-related topics and ensure compliance with safety legislation.

Knowledge, Skills, and Abilities:

Required:

• Strong leadership and managerial skills.

• Proficiency in Microsoft Windows and Office Professional (Word, Excel, and

PowerPoint), with knowledge of healthcare-related computer technology.

• Expertise in audit and investigatory processes.

• Excellent organizational skills to prioritize workloads and meet deadlines.

• Ability to develop and implement policies and procedures.

• Competence in teaching and evaluating clinical performance.

• Proficiency in using data-driven strategies to improve patient outcomes and apply

insights from quality measure benchmarking.

• Capability to align improvement initiatives with the organization's strategic plan.

• Skill in implementing risk management training, tracking tools, and interventions.

• Strong interpersonal skills to collaborate effectively with cross-functional teams and

develop solutions to operational challenges.

• Ability to communicate the impact of quality initiatives on federal and state

payment/reimbursement programs.

• Excellent writing and presentation skills.

• Ability to maintain confidentiality of documents and information.

Preferred:

• Broad-based knowledge of the operations of a community health center.

• Familiarity with FTCA requirements, HRSA guidelines, NCQA standards, and Lean

principles and methodologies.

• Knowledge of compliance and performance improvement practices.

• Understanding of non-profit accounting methods and regulations.

• Demonstrated ability to develop studies and conduct reviews using measures or

indicators

Credentials and Experience:

Required:

• Bachelor's degree in finance, nursing, healthcare administration, or a related field.

• Three years of healthcare experience, with two years in a senior supervisory role.

• Ability to maintain confidentiality.

Preferred:

• Master's degree in finance, nursing, healthcare administration, or a related field or

equivalent.

• Nonprofit and health center experience.

• Knowledge of community health center operations, compliance, and performance

improvement.

• Familiarity with FTCA, HRSA, NCQA standards, and Lean principles.

• Understanding of non-profit accounting methods

• Experience with grants and accounting systems

• CCQO certification

Special Requirements:

• Pass a stringent screening to determine any history or record of any misconduct or

criminal activity

• Have credible references to qualify

• Requires sitting, standing, and walking for extensive periods of time. Requires working

under stressful conditions or working irregular hours. Requires frequent exposure to

communicable diseases, body fluids, toxic substances, medicinal preparations, and other

conditions common to a clinic environment. The employee frequently is required to reach

with hands and arms. Specific vision abilities required by this job include close vision,

distance vision, color vision, peripheral vision, depth perception, and the ability to adjust

focus. Ability to work with a moderate noise level in the work environment is required.

The above information is intended to describe the most important aspects of the job. It is not

intended to be construed as an exhaustive list of all responsibilities, duties, and skills required to

perform the work. The health center reserves the right to revise or change job duties and

responsibilities as the business need arises. Additionally, this job description is not intended as an

employment contract, implied or otherwise, and the Center continues to maintain its status as an

at-will employer.

If the essential functions of this position cannot be performed in a satisfactory manner by the

employee, reasonable accommodations may be made.