POSITION SUMMARY:  This position serves as the Quality Assurance / Quality Improvement (QA/QI) at NATIVE HEALTH. The facility serves the patients that are members of Indian Tribes throughout the Phoenix area. The primary responsibility of this position is to assure that the quality improvement activities are performed so that the highest possible quality and level of health care may be met and maintained. The incumbent is responsible for developing, implementing, monitoring, and evaluating all of the quality improvement and risk management programs at NATIVE HEALTH.

The QA/QI is also responsible for directing, assisting and guiding management and staff toward establishing, maintaining and/or improving systems of professional standards review, retrospective and concurrent patient care evaluation activities, utilization review, risk management, and overall quality improvement of the program. The QA/QI will conduct inventories and monitors the existing system, identify and analyze deficiencies, assist in developing the completion of corrective actions and their effectiveness. The QA/QI will report directly to the Health Services Administrator. 

Essential Functions: Essential functions as defined under the Americans with Disabilities Act may include the following tasks, knowledges, skills, and other characteristics. This list of tasks is not a comprehensive listing of all functions and tasks performed by position in this class and are subject to change.

Evaluation: Performance of this job will be evaluated in accordance with provisions of the NATIVE HEALTH Employee Handbook on evaluations.

RESPONSIBILITIES AND DUTIES:

1. Develops implements and maintains specific systems for the assessment of services and the correction of deficiencies identified in the assessments. 
2. Establishes criteria and standards for highest achievable quality of health services based on, but not limited to, discharge planning, AAAHC accreditation surveys and all aspects of ambulatory accreditation standards and policies of the AAAHC.
3. Develops and directs the risk management program to minimize the risk of personal injury to patients, staff, and visitors.
4. Maintains records and monitors health care and programs that are in place.
5. Conduct regularly scheduled analyses of these systems to identify deficiencies and assists in developing plans for corrections.
6. Periodically reviews and/or develops elements of the quality improvement and professional standards review program, especially in terms of identification of resource commitments.
7. Makes assignments and indicates priorities to subordinates in terms of the following functions; utilization review, patient care evaluation studies, AHCCCS and licensures criteria and procedures.
8. Consults on and develops mechanisms to evaluate the services these entries document and to evaluate the completeness of the documentation of services rendered.
9. Establishes, in conjunction with various health care disciplines, written standards of care criteria, which are specific, for the services provided and the personnel involved in the provision of these services.
10. Actively participates in all aspects of the facility quality improvement program, including medical patient care, patient, visitor, and employee environment safety: infection control, disaster program, employee health, and any other program, which reflects on the quality of care delivered by facility.
11. Participates in research and educational studies and activities related to quality improvement activities. Provides information pertinent to the study and serves as a resource person. Reviews, analyzes, and interprets data based on knowledge and judgment resulting from experience, education, professional background and familiarity of the quality improvement program.
12. Provides expert consultation on the comparison of data on health and medical care administered by health care systems in comparison with adopted norms, standards and criteria.
13. Evaluates the functions and activities of the health care systems committees, governing body and departments to ensure accreditation standards and criteria in order that the highest achievable quality of care may be delivered.
14. Provides ongoing and in-service training to NATIVE HEALTH personnel in areas relating to quality improvement. May periodically provide information or training to community, professional special interest groups and associations.
15. Perform other duties as assigned.

KNOWLEDGE, SKILLS, AND ABILITIES:

1. Professional knowledge in a field relating to the health care sciences pertinent to the work of this position (i.e., clinical care professions such as nursing, medical technology, etc.).
2. A working knowledge of problem oriented medical records.
3. Comprehensive knowledge of institutional and regional health care systems, to serve as an authority in matters pertaining to health care systems.
4. Ability to communicate successfully both orally and written, with a variety of individuals, health care professionals, and other NATIVE HEALTH employees, governing body, etc.
5. Ability to successfully perform duties such as developing procedures, planning, organizing and monitoring studies involving analysis of data and preparing reports.
6. Knowledge of and ability to interpret standard of accreditation such as AAAHC, AHCCCS, licensures, etc. and the ability to apply these standards to varying clinical settings.
7. Demonstrated leadership abilities, especially in a multidisciplinary clinic atmosphere; to negotiate, and to elicit cooperation.
8. Maintain professional knowledge and proficiency in quality improvement programs and his/her own field of expertise through continuing education courses, conferences, workshops, etc.
9. Possess and/or acquire knowledge and familiarity in other health care disciplines other than his/her own.
10. Knowledge of the cultural, social, and economic backgrounds of the population served by NATIVE HEALTH.