Position Summary

As a member of the Quality Team, the Director of Nursing coordinates and supports the strategic implementation and day-to-day operations of Minnesota Community Care’s Risk Management and Quality Improvement Program to ensure alignment with organizational goals and compliance with regulatory requirements from the Health Resources and Services Administration (HRSA), the Centers for Medicare and Medicaid Services (CMS), the National Committee for Quality Assurance (NCQA), Federal Tort Claims Act (FTCA), Occupational Safety and Health Administration (OSHA) other applicable accrediting or regulatory state and federal governing bodies. The Director of Nursing collaborates across departments and service lines f to design, implement, and review system wide quality improvement activities, promoting an environment of evidence-based practice and continuous quality improvement. This role manages key operational and reporting components of the quality program and supports the development and execution of initiatives that enhance care quality, clinical outcomes, and patient experience.

Key areas of responsibility include:

Quality assurance and quality improvement
Patient Centered Medical Home program
Infection Prevention and Control
Nursing standard of practice, performance improvement, and quality outcomes
Staff education, training, and competencies
Safety culture and emergency preparedness
Collaboration and consultation with the county and state Departments of Health and related agencies
Internal and external data collection and reporting
Root Cause Analysis
Care coordination and integration
May be responsible for performing ADON duties at assigned clinic/site(s)

Essential duties and functions
An individual in this position must be able to successfully perform the essential duties and responsibilities described. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions of this position.

Leadership and Strategic Oversight:

Co-lead system-wide quality assurance (QA), quality improvement (QI), and risk management strategies
Serve as the organization’s designated Infection Preventionist.
Co-manage the organization’s accreditation (e.g., NCQA PCMH) and compliance programs (e.g., FTCA, HRSA OSV).
Provide expert consultation on regulatory and compliance requirements.
Collaborate with clinical and operational leaders to align quality goals and initiatives with organizational strategy.
Facilitate and participate in internal and external committees to help maintain forward momentum in achieving organizational goals and objectives.
Lead development of nursing care standards, orient/train staff and provide ongoing monitoring.
Lead the Safety & Infection Control Committee and other meetings as assigned.
Liaise with clinical teams regarding the development of standards, audits, and

Quality, Compliance, and Risk Management:

Oversee development and implementation of annual Risk Management and Infection Control Plans and evaluations.
Facilitate organizational preparation for regulatory and accreditation site visits and audits.
Facilitate root cause analyses (RCAs), peer reviews, and manage follow-up actions from safety events or complaints.
Lead regulatory survey preparation and document collection.
Coordinate the annual infection control risk assessment in conjunction with the Accreditation, Compliance & Quality Coordinator
Work collaboratively with the leadership team to ensure overall achievement of system and site quality improvement initiatives.
Establish annual goals and objectives, and methods of evaluation for areas of responsibility. Oversee performance through periodic surveys and monitoring of quality measures. Assist to operationalize improvement opportunities.

Patient Safety & Incident Management:

Review all Nursing and support staff incidents and ensure appropriate follow-up by the manager responsible to support timely resolution and closed-loop communication.
Manage ongoing use and implementation of Compliatric (incident tracking, policy management, training compliance).
Administer employee surveys (e.g., Patient Safety Culture) and develop organization-wide action plans.
24-hour infection control and prevention consultation regarding the management of infectious patients/residents and other infection-prevention issues
Develop, implement, and evaluate Minnesota Community Care’s annual infection prevention plan in accordance with CDC, CMS and NCQA requirements
Present the infection prevention annual report to the IPC, Quality Board, and Executive Leadership Team; to include results, goal achievement, and areas for improvement
Clinical and community surveillance of infections to help mitigate the spread of infectious diseases
Provide education and training for all staff members, independent practitioners, and contractors regarding the infection prevention program
Cooperate with the county and state department of health regarding infectious and communicable disease reporting

Performance Improvement & Training:

Facilitate Clinical Integration Committee and oversee the implementation of workgroup priorities (e.g., Diabetes, Immunization).
Oversee quarterly and annual clinical performance reporting (e.g., UDS, NCQA).
Maintain training plans in Compliatric and track staff completion of clinical competencies and mandatory training.
Support the onboarding training for new staff, including safety orientation, immunization, and TB screening coordination.
Develop annual training program, education priorities, and competency assessments for nursing and other clinical support staff; work with ADONs to assess staff competency. Oversee completion of competency assessments and required staff training.
Ensure the completion of audits in compliance with selected policies

Program Management:

Lead FTCA application and compliance readiness annually.
Co-lead NCQA PCMH accreditation with TA support.
Direct the Immunization Program, including training, reporting, and compliance with MNVFC requirements.
Serve as MIIC administrator for vaccine reporting and reconciliation.
Partner with leadership on cross-departmental projects such as incident system migration and the Empanelment workgroup.
Administratively support the organization wide policy management program.
Other duties as
Lead Care Coordination program for the organization; including standard implementation for PCMH and Minnesota’s Health Care Home program.

Site Specific Responsibilities
May be responsible for and appropriately delegate ADON duties at an assigned clinic/location(s) which include and are not limited to the following:

Directs and monitors operational performance of the clinic; examines activities of the clinic to determine their necessity and how they interface intra and inter-departmentally.
Periodically monitors schedules and clinic services to ensure that appropriate staffing is available to meet patients’ needs. This includes problem solving scheduling and clinical workflow issues in real time thereby ensuring optimal clinical flow for both providers and patients.
Oversees completion of MA and RN staffing schedules to ensure optimal allocation of staff.
Establishes appropriate type and levels of clinical support staff.
Ensures the ongoing training and development of clinical support staff
Leads and coaches clinical support staff and medical providers in maintaining clinic flow, efficiency, quality of care and customer service to meet WSCHS standards.
Selects and hires employees according to established guidelines. Monitors, coaches, develop and evaluate performance of staff on an ongoing basis in accordance with applicable performance standards. Supervises, either directly or indirectly, non-LIP staff
Completes timecards and coordinates Paid Time-Off (PTO) requests for staff.
Oversees/assists with inventory management and ordering of clinical supplies and pharmaceuticals.
In conjunction with facilities management, ensures medical equipment is in good condition and is functioning properly; ensure regular maintenance and calibration. Recommend purchases of new or replacement equipment as needed.
Acts as or oversees the work of the Immunization Coordinator for the Minnesota Vaccines for Children and Uninsured and Underinsured Adult vaccine programs. This includes performing private and public vaccine ordering, inventory, documentation, record keeping, and staff education.
Ensure compliance with infection control and safety and regulatory requirements, i.e., OSHA/The Joint Commission. Ensures monthly QA activities are completed and submitted.
In collaboration with the facilities management, ensures that clinic facilities and grounds are safe, clean and well-maintained.
Coordinates and leads clinic team/site meetings.
Other duties as assigned

SUPERVISORY RESPONSIBILITIES
This position has overall supervisory responsibility for MA supervisors, registered nurses, licensed practical nurses, medical assistants, EMTs, x-ray techs, interpreters and related personnel at assigned clinic location(s). This position has overall supervisory responsibility for all associate directors of nursing

PHYSICAL DEMANDS AND WORK ENVIRONMENT
This position is very active and requires standing, walking, listening and speaking. This job operates in a healthcare setting. This role requires regular walking to various locations around the clinic. This role also routinely encounters patients who may have contagious illnesses.

REQUIRED QUALIFICATIONS

Registered Nurse, active and unrestricted
Master’s degree in nursing required; doctoral degree preferred.
At least 5 years as a registered nurse preferable in non-profit or community healthcare
3+ plus years progressive leadership experience
Experience in infection control – preferred
Basic Life Support required

TECHNICAL COMPETENCIES
A full list of current competencies is available by asking the supervising manager. They include, but are not limited to:

Infection Preventionist Competency
Vital Signs Competency
Immunization Competency
Rooming Competency
Instrument Cleaning/Disinfection/Sterilization Competency
Hand Hygiene Competency
EKG Competency
Spirometry Competency

KEY COMPETENCIES

Commitment to driving diversity, equity and inclusion
Excellent verbal and written communication skills
Excellent interpersonal and negotiation skills
Excellent organizational skills and attention to detail
Excellent time management skills with a proven ability to meet deadlines
Strong critical thinking skills
Excellent communication, leadership, and planning skills
Ability to adapt to the needs of the organization and employees

Who We Are

As Minnesota's largest Federally Qualified Health Center, Minnesota Community Care ensures that the communities we serve have access to high quality and affordable health care. Our patients predominantly identify as people of color (80%), low-wealth (61% patients = 200% FPL), and un/under-insured (40% uninsured, 45% publicly insured) (UDS, 2020).

We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability status, protected veteran status, or any other characteristic protected by law. Minnesota Community Care values building a culturally diverse staff that reflects the communities it serves, and strongly encourages women, minorities, and persons with disabilities to apply. Minnesota Community Care is committed to providing Equal Employment Opportunities to all applicants. EO M/F/Disability/Vet Employer.