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Responsibilities
- Coordinate NYSDOH/CMS & TJC data collection and submission per policy and procedure.
- Develop policies and procedures that adhere to best practices and evidenced-based practices within the context of regulatory guidance.
- Maintain all NYSDOH, Primary Center’s Stroke Team’s education requirements annually.
- Oversee performance improvement, P&P, physician relations, program development, education, and community outreach strategies.
- Assist in overseeing duties and functions necessary to assure regulatory and accreditation compliance.
- Advise the vice president and hospital staff on regulatory and accreditation compliance issues.
- Assist in coordination of regulatory survey and reporting activities within the organization.
- Ensure staff compliance with patient safety goals and compliance with TJC, NYSDOH, CMS, and other regulatory standards.
- Collaborate with cross-functional teams to deliver enterprise quality solutions.
- Monitor the QA process daily, weekly, or monthly to ensure methods are followed.
- Reinvest in regression testing procedures, test plans, and staff education.
- Maintain knowledge of internal systems to provide support to QA staff.
- Define and implement testing methodology that incorporates best practices for new systems and current system enhancements.
- Develop QA metrics and targets for processes and initiatives to assure all manual and electronic (EHR) documentation formats work independently and together in a high-quality manner.
- Act as a visible champion for QA to both internal and external clients.
- Develop and monitor unit/department specific QA/PI plans, initiating appropriate action to improve outcomes.
- Monitor and assist in development of initiatives/measures to mitigate patient safety indicators (PSIs) and hospital acquired conditions (HACs).
- Support improving overall patient care through cross interactions with Risk Management, Graduate Medical Education HIM/Coding, and other applicable areas.
- Coach, mentor, and lead team members to achieve position requirements and individual career goals.
- Direct National Hospital In-patient and Out-patient Quality Reporting Program (Core Measures) and maintain associated dashboards.
- Chair Core Measure Team Meetings for reviewing dashboards, outcomes, and corrective actions required for performance improvement, patient safety, and staff education.
- Coordinate evidenced-based medicine and performance improvement activities of the clinical staff, including Core Measures and other internal and external quality initiatives.
- Serve as liaison between the hospital and NYSDOH.
- Participate in and/or coordinate the functions of various hospital-wide quality committees.
- Serve as consultant to Medical Staff Committees and Department Managers as needed.
- Work collaboratively with physicians, nurses, case managers, and other healthcare disciplines utilizing a team approach.
- Act as clinical consultant regarding excellence in clinical care for the Sepsis patient population.
- Collaborate with the Stroke Coordinator regarding data collection & analysis that may impact outcomes and continuous performance improvement.
- Ensure continuity between clinical practice and standards of care to patients with sepsis.
Requirements
- Minimum formal education of Bachelor's Degree.
- Minimum of 3-5 years job-related experience.
- RN License preferred but not necessary.
- Previous experience in quality/regulatory required.
Work Type
- Full-time
Experience Level
- 3-5 years
Education Level
- Bachelor's Degree
- RN License preferred
Salary/Compensations
- $145,000 - $165,000