Director of Quality Management- Gotham Health

About NYC Health + Hospitals

NYC Health + Hospitals/Gotham Health is one of the largest Federally Qualified Health Center (FQHC) in the country, providing coordinated world-class primary and specialty care with dignity and respect for all New Yorkers, without exception. At Gotham Health, we practice a person-centered caring culture that values delivering compassionate, quality healthcare in partnership with our patients, community organizations, and staff. Gotham Health is focused on high-quality, affordable care to everyone regardless of ability to pay or immigration status. Gotham Health serves the community through a two-pronged approach: providing treatment to those who need it while at the same time emphasizing prevention. We strive to deliver services in a way that maximizes each patient's opportunity to achieve successful health outcomes, we believe in every person's right to participate in their care plans, we facilitate partnerships with other community resources to meet the needs of our patients beyond healthcare, and we celebrate and recognize the compassionate care of our committed staff. Join our team if you want to be part of our Gotham Health Family, a person-centered, fully integrated, and innovative ambulatory care network that enables all New Yorkers to live their healthiest lives.

At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.

Job Description

PURPOSE OF POSITION

Under the guidance of the Gotham Health Chief Quality Officer, the Senior Director ("Director"} of Quality Assurance and Performance Improvement (QAPI) will play a crucial role in the quality efforts of Gotham Health, the nation's largest Federally Quality Health Center.

Through oversight and management of a multifaceted team, the Director will help lead performance Improvement activities and also oversee Gotham Health's fulfilment of quality assurance requirements as put forth by Health Resources and Services Administration (HRSA), New York State Department of Health, Gotham Health's annual performance improvement plan, the NYC Health+ Hospitals' Quality Assurance/Performance Improvement (OAPI) Committee of the Board of the Directors, among others.

The Director will monitor progress of quality-related activities, highlight successes and address challenges, and act as a crucial liaison between Gotham Health's clinical sites and internal and external stakeholders. Using their expertise, the Director will function as a subject matter expert and professional lead in assigned areas.

The Director will assist the Gotham Health Chief Medical Officer in collecting and assembling the quarterly NYC Health + Hospitals QAPI Committee board report materials and oversee staff members that report to the Senior Director to assist with this important function. The Director will also advise Gotham Health Executive Administration on areas for improvement, including opportunities for quality-related incentives from health insurers and other entities.

SUMMARY OF DUTIES AND RESPONSIBILITIES

• Oversee the quality assurance functions, including to present to the Gotham Board and Gotham Health QA/Pl Committee the clinical performance of Gotham Health, including quality indicators, patient complaints/grievances and compliments, results of regulatory surveys, patient and staff satisfaction results, issues with environmental safety, risk management issues, employee and patient occurrences, and the credentialing process.

• Oversee the practice, and in some cases development, of policies, procedural guidelines as well as the monitoring and evaluation techniques for the performance improvement and quality reporting activities established by the Gotham Health Board of Directors and Quality Assurance Committee.

• Provide advisory guidance to Gotham Health site administrators, medical directors, and clinical staff related to performance improvement activities, informed by quality metric reporting, with focus on improving patient care. This will include disseminating quality metrics and survey results, e.g., Article 28 surveys, as methods to help prioritize areas for improvement.

• Manage a staff of performance improvement advisors to design, develop, execute, and evaluate quarterly performance improvement activities chosen by Gotham Health and per the Quality Assurance/Performance Improvement (QAPI) Committee of the Board of the U1 rectors for NYC Health + Hospitals (H+H).

• Manage a staff of QA coordinators in Gotham Health who organize reportable data.

• Prepare summaries of 11 t 11 QAPI Committee board reports for Gotham Health's QA Committee, identifying trends, best practices, and areas for follow-up.

• Prepare and monitor Gotham Health's annual performance improvement plan as required by HRSA and NYC Health+ Hospitals.

• Prepare and monitor HRSA's Uniform Data System report annually, working with Gotham Health finance team and IT team as needed, to submit report to HRSA.

• Monitor indicator data across Gotham Health using existing data platforms in order to assist in developing strategies for improving patient satisfaction efforts.

• Monitor patient satisfaction data and patient complaints/grievances across Gotham Health in order to assist in developing strategies for performance improvement around care experience.

• Monitor QARR results of Gotham Health in order to develop strategies to increase performance and maximize revenue capture.

• Monitor performance of population health indicators as reported by federal, state, and insurance companies in order to develop strategies for improvement.

• Be aware of and identify incentive payment opportunities from insurance companies that improve Gotham Health's financial sustainability and quality of care and oversee a staff focused on managed-care incentives.

• Work with Gotham facilities to further enhance their QA/Pl internal committees to focus on performance improvement activities, involving front line clinicians and staff.

• Other related duties, as required.

Minimum Qualifications

1. Master’s degree from an accredited college or university in Quality Management, Hospital Administration,

Health Care Administration, or in a related health care specialization; and five (5) years of experience in the

development of organizational strategies and implementation of staffing plans, regulatory survey preparation

and compliance, and in performance improvement and/or continuous quality improvement (CQI) initiatives in a

hospital or health care setting, three (3) years of which must have been in a responsible administrative,

managerial or supervisory capacity; or,

2. Bachelor’s degree in the disciplines as described in “1” above; and seven (7) years of related experience, as

listed in “1” above, five (5) years of which must have been in a responsible administrative, managerial or

supervisory capacity; or,

3. Bachelor’s degree in the disciplines as described in “1” above; and two (2) years of clinical, patient care or

equivalent experience in a hospital or health care setting, plus three (3) years of related experience, as listed

in “1” above, one (1) year of which must have been in a responsible administrative, managerial or supervisory

capacity; or

4. A satisfactory equivalent of education, training, and/or experience. Certified Professional in Healthcare Quality

(CPHQ) may be substituted for one (1) year of experience, however, all incumbents must have at least a

bachelor’s degree and one (1) year of responsible administrative, managerial or supervisory experience, as

described in “1” above.

Department Preferences

• Preference will be given to candidates with:
• Comprehensive knowledge of quality improvement and quality assurance principles and practices.
• Working knowledge of FQHC requirements, such as UDS, is strongly desired.
• Knowledge of principles and workflows for health care delivery systems generally.
• Ability to identify and implement clear plans including all necessary evaluation and follow-up reports.
• Ability to communicate effectively, timely, and constructively with all levels of staff from senior leadership to frontline health care team members in order to coach, assist, and promote a culture of improvement.
• Advanced skills in writing, spread sheets, and statistical analysis.
• Strong interpersonal, written and verbal skills, with the ability to deliver complex information in a manner that is understandable, transparent, and on a need-to-know basis and in forecasting potential areas of concern.
• Ability to structure and manage group processes and a track record of managing multiple team members.
• RN degree or higher-level nursing training (e.g., NP) or doctorate-level training (e.g., PhD, DNP, PsyD) with at least 5 years of progressively responsible experience in quality assurance and/or quality improvement activities, preferably in primary care.