Director of Quality and Organizational

POSITION-SPECIFIC COMPETENCIES/ESSENTIAL FUNCTIONS/DUTIES & RESPONSIBILITIES

• Under the leadership of the CMO, facilitate the development, implementation, and quarterly review of the MHSI Continuous Quality Improvement Program Plan (CQIP).
• Coordinate, facilitate, and document the work of the CQI Committee, including agendas, minutes, dashboards, and formal reports.
• Oversee the collection, validation, analysis, and reporting of HRSA Uniform Data System (UDS) measures, ensuring accuracy, completeness, and consistency with HRSA guidance.
• Partner with clinical, operations, IT, and billing teams to ensure EHR workflows, data definitions, and documentation practices support reliable UDS reporting.
• Monitor UDS clinical quality measures, patient demographics, utilization, and outcomes to identify performance gaps, trends, and improvement opportunities.
• Translate UDS findings into actionable performance improvement initiatives across Primary Care, Behavioral Health, Dental, Pharmacy, Ryan White, WIC, Podiatry, and Human Services.
• Ensure timely submission of UDS reports, support internal validation processes, and respond to HRSA inquiries, audits, or data verification requests.
• Identify, assess, prioritize, and monitor quality improvement opportunities related to ambulatory care delivery and population health outcomes.
• Oversee and/or conduct EHR-based audits, chart reviews, quarterly peer review activities, and data validation exercises supporting UDS, quality metrics, and payor reporting.
• Publish and communicate audit findings, UDS trends, and performance results using standardized dashboards for leadership, the Board of Directors, and external stakeholders.
• Provide education and training to staff, leadership, and the Board on CQI principles, UDS measures, HRSA expectations, and performance improvement strategies.
• Collaborate with external agencies (e.g., WPHCA, HRSA partners, quality collaboratives, and payor initiatives) and represent MHSI in UDS-related learning networks and performance improvement forums.
• Coordinate with senior management, compliance, and the executive team on policies and procedures related to HRSA 330 compliance, accreditation readiness, and reassessment activities.

• Lead the agency's Risk Management Plan, coordinating enterprise risk identification, mitigation, monitoring, and reporting activities across the organization.
• Establish policies and procedures for the identification, collection, analysis, trending, and reporting of risk-related data, including clinical, operational, patient, and employee risks.
• Educate staff and leadership on risk management expectations, reporting requirements, and mitigation strategies.
• Utilize Failure Mode and Effects Analysis (FMEA) methodologies to proactively identify system vulnerabilities and ensure high standards of quality, patient safety, and operational reliability across the organization.
• Advise departments and programs on risk mitigation, incident prevention, and corrective action planning.
• Collect, evaluate, and maintain data related to patient and employee injuries.
• Conduct or oversee internal investigations and root cause analyses to identify systemic risks, reduce liability exposure, and prevent recurrence.
• Prepare and present the comprehensive annual risk management and quality progress reports to senior management and the CQI Committee.

• Receive, investigate, and evaluate reports of accidents, adverse events, and near misses involving patients or employees.
• Monitor departmental safety investigations to ensure timely completion, procedural integrity, and appropriate follow‑up.
• Maintain and oversee an internal safety event reporting system, providing quarterly summaries and trend analyses to the President/CEO and senior management team.
• Facilitate and coordinate safety training programs and resources for staff across disciplines according to payor and regulatory requirements.
• Coordinate with compliance and operations on the annual organizational safety audit(s).
• Promote a culture of safety, transparency, and continuous learning throughout the organization.

• Lead and coordinate the health center's enterprise risk management program in collaboration with the Chief Operations Officer and under the oversight of the Chief Medical Officer, ensuring that risk assessments are conducted, documented, reviewed, and acted upon at least quarterly in accordance with HRSA FTCA requirements and Health Center Program Compliance Manual Chapter 21.
• Prepare and present the annual Risk Management Report to the Board of Directors, summarizing enterprise risk assessment findings, mitigation strategies, trends, and performance against established risk management goals, and recommending corrective actions as necessary to support FTCA compliance, patient and employee safety, and effective Board oversight.
• Participate in leadership councils and strategic planning activities to ensure that…