Indian Preference:  Consistent with Public Law 93-638 and other federal laws recognizing the inherent right of the Tribe to exercise Indian Preference.

Must be fully vaccinated for COVID-19 including two (2) doses of a 2-dose series or one (1) dose of a 1-dose series plus fourteen (14)( days beyond the final dose prior to start date

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

The Quality Improvement Specialist representative will assist the Quality Director in planning and coordinating activities to develop, implement, support, and promote quality improvement programs.  May lead quality initiatives to improve quality of care and services for KIC Tribal Health Clinic (KICTHC) patients and staff. Evaluates and analyzes the effectiveness of quality improvement activities. 

Assist the Quality Director in the effective operations and/or oversight of performance improvement, including quality, risk, patient safety, core measures, data analysis/ review/ trending/ solutions, regulatory and accreditation, and process improvements. This position works closely with Administration, Providers, and staff to ensure awareness of quality and patient safety, and to facilitate improvement efforts in all areas. Staying abreast of the most current quality, regulatory and performance measures and initiatives is vital to the success of this role. This position manages significant clinical events investigations and reporting; coordinates regulatory surveys; facilitates education and training around quality and safety; chairs workgroups; completes process reviews; oversees data, and serves as the expert for performance and quality improvement. All work is considered confidential and protected from discovery, pursuant to applicable state law.

Maintains performance improvement activities within the department and participates in accreditation activities for KICTHC. Assumes supervisor duties during his/her absence and performs other duties as assigned

 

ESSENTIAL JOB FUNCTIONS

 

Resolves Problems

Attends and participates in appropriate administrative, and workgroup meetings.

Provides support functions related to quality improvement activities. Develops patient feedback assessment activities, including patient surveys. Identifies and develops relationships with all departments involved in the care of patients. Continuously informs all clinic staff of a Quality Improvement Specialist representative’s role.

 

Clinic Guidelines

Adheres to KICTHC policy and procedures for the HIPAA Security and Privacy Act regulations.

Complete understanding of 42 CFR Part 2 and Indian Health Service regulations required.  Adheres to KICTHC Compliance Plan and the standards of ethics in the current ordinance 8.

 

Maintains Quality Results

Assist in identifying and monitoring KICTHC performance indicators to ensure optimal patient care.

Partners with programs and working with multi-disciplinary teams to maintain or establish accreditation readiness by coordinating key aspects of regulatory requirements including but not limited to knowledge of the standards, maintenance, relevant documentation history, completion of accreditation documentation requirements, participates in accreditation teams and carries out associated annual plan work.

 

Collects, analyze, and summarize information and trends.  Plan, coordinate, and implement quality improvement projects and educational activities as follows:

 

Facilitate collaborative work sessions to discuss quality issues, projects and programs. Complete audit and submission requirements, as specified by regulatory bodies/purchasers.  Assist with data analysis and report creation to support the activities within KICTHC.  Perform barrier and root cause analyses to identify improvement opportunities.  Identify best practices, and share across KICTHC network.

 

Assist with the development, implementation and maintenance of a strong Quality Plan. Quality measures and initiatives are facilitated and promoted, with compliance monitored and reported in an appropriate and timely manner. Offers feedback, suggestions and problem solving to ensure that the Quality Department and Plan guide improvement efforts; skilled at using data, chart reviews, and other QAPI tools/methodologies to carry out an effective Quality Plan. Performs investigations and surveys, generates reports, maintains records and recommend adjustments in policy and procedures.

 

Develops, maintains and utilizes sound working knowledge of accreditation and regulatory standards and serves as primary resource for interpretation and application of. Facilitates/coaches/guides managers and staff to better understand regulatory standards and how to meet these in the most proficient manner for the organization and resources allotted. Also responsible for assuring appropriate action plans are developed, implemented and monitored based on data and leading practices as needed to meet regulations.

 

Works closely and collaboratively with the Quality Director, Medical Director, and other Leaders on quality assessment and risk management issues. Investigates all concerns, trends, or risk factors that present risks or safety concerns to patients and the organization. Maintains professional relationship with liability insurance carrier and legal counsel when investigating and processing any risk claims. Has a keen understanding of the Incident Reporting system. Supports supervisor to ensure all applicable quality processes are in place and sustained; serves workgroups or attends meetings as a representative of the Quality department. Compiles and provides required reporting to senior management for established quality monitoring items and attends meetings as needed.

 

KIC COMPETENCIES

 

Cultural Competency: To be respectful and responsive to the health beliefs, practices, and cultural and linguistic needs of KIC Tribal Members. Developing cultural competence is an evolving, dynamic process that takes time and occurs along a continuum.

 

Commitment: To serve Tribal Members and set a high standard for yourself in your performance; strive for results and success; convey a sense of urgency and bring issues to closure; and stay persistent despite obstacles and opposition. 

 

Customer Service: Meet/exceed the expectations and requirements of internal and external customers; identify, understand, and monitor the needs of both internal and external customers, always talk and act with customers in mind; and recognize working colleagues as customers.

 

Effective Communication: Ensure important information is passed to those who need to know; convey necessary information with respect, clearly and effectively orally or in writing

Responsiveness and Accountability: Demonstrate a high level of conscientiousness; hold oneself personally responsible for one's own work; and do the required fair share of work.

 

Knowledge, Skills, and Abilities Requirements

• Knowledge and demonstrated understanding of healthcare policies and procedures including safety issues;
• Knowledge of excellent computer and analytical skills necessary to maintain centralized reporting and tracking systems to identify trends and evaluate problems and assessing the potential harm if the problems are not addressed;
• Knowledge of the Health Insurance Portability and Accountability Act (HIPAA);
• Skilled in strong interpersonal and communication essential to facilitate smooth resolution of conflict between the staff and a patient and/or family member or a visitor;
• Skilled in sound judgment is required to know how to proceed, and with whom to seek advice regarding the issues which arise (problem resolution skills);
• Skilled in good judgment, assertiveness, and dependability in the performance of his/her role as the Quality Improvement Specialist representative;
• Skill to operate software programs with knowledge of control charts and Microsoft applications;
• Ability to communicate professionally over the telephone and in person in a positive and clear manner with clinic, administrative personnel at all levels, and the public;
• Ability to be an informed regulatory healthcare representative for the patient and organization; must be able to communicate patient rights and responsibilities to patients, family members, and staff. Sensitive to the needs of patients and employees.
• Ability to deal tactfully with extremely sensitive issues relating to patients.
• Ability to deal effectively with a variety of people in situations which are often difficult and demanding (crisis intervention skills).
• Ability to be flexible and to perform efficiently and competently
• Ability to manage multiple tasks, including telephone, computer operations and in-person visits simultaneously;
• Ability to take verbal instruction and complete assigned project by established deadline;
• Ability to be flexible in order to perform at the highest level as a team player;
• 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 (both patients and co-workers);
• Ability to work independently with minimal supervision and able to prioritize assignments;
• Ability to maintain confidentiality of all KIC operations and staff.
• Knowledge of accreditation requirements for an ambulatory healthcare system.
• General knowledge of organizational functions and operations.
• Knowledge of group processes and ability to lead teams.
• Math or analytical judgment skills.
• Ability to define problems, collect data, establish facts, and draw valid conclusions.
• Other duties as assigned

 

Physical Activities

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 ten (10) pounds.

 

Writing by hand and using a personal computer. Long hours in front of computer screen.  Traveling occasionally, to out-of-town meetings and functions.

 

Working Conditions

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 patients and/or family members.

 

QUALIFICATIONS

 

Licensure

Possess current valid State of Alaska driver's license with a record acceptable to KIC’s Insurance carrier.

 

Education

Bachelor of Arts in Healthcare management or equivalent related professional working experience.

 

Experience

Three years’ work experience in health care related activities which include monitoring clinical quality, planning, and coordinating process changes.